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Insurances combining 90716 and 90707 to pay 90710

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sbeall73

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5
Location
Warrenton, VA
We do not administer 90710 MMRV. We do not have that vaccine in our office. Our providers prefer to give MMR (90707) and Varicella (90716) separately. In the past two weeks, 3 insurances now have changed 90716 and 90707 to 90710 on our EOB's and paid our claims as a 90710 instead of paying them separately, as they have always done. I cannot find any research anywhere on this to explain why. When I call the insurances, they said "we are paying at the highest level of service". But this is not what we billed, or administered. Are any other pediatricians seeing this?
 
We are noticing the same scenario with a couple insurances also. We do not offer this combination shot and the insurance companies are bundling it to the 90710. Please advise if advice for this issue?
 
According to information provided by one insurer: " a rebundling edit identifies two or more procedures used to report a service when a single, more comprehensive procedure code exists that more accurately represents the service performed. Occasionally, the code that represents the comprehensive procedure is added to the claim resulting in the component procedure being disallowed. To correct this type of coding error, the unbundled procedure code(s) is rebundled to the comprehensive procedure code." So, since 90707 and 90716 lie inside the 90710 code, 90716 or 90707 would be disallowed when billed with each other. However, each should be payable if they are given separately, like at different encounters on different days.
 
I just had my 1st experience this week, my carrier is Anthem. I submitted an online clinical dispute with documentation from the CDC stating that it is recommended to give Varicella and MMR separately. Anthem upheld their decision and now I am filing a grievance.
 
I was told by our home office that BC/BS had fixed the problem and would be reprocessing claims. Non the less, I messaged via Availity every claim that was denied and explained the situation. I have received payment on several of my January claims. However, they did pay the 90710 instead of the two separate immunizations which is a slightly higher payment.
 
This is happening at my practice with Aetna and Cigna. Multiple appeals and denials and I was informed that this is a rebundling edit that will continue to occur. Given that the reimbursement is more than the two individual CPT codes, I am no longer fighting this. It does not make sense from a billing standpoint given that the NDC would be different but I am not going to continue to waste time fighting something for less money.
 
We have had the same thing happen at our Pediatric Practice. In the McKesson claim edits on the payer websites for the two payers that have done this the edit is a clinical claim edit in their system. In one of the payer's McKesson Claim edit search criteria we have to enter the NDC # on the vaccine CPT line. I feel like this is a McKesson Claim Edit error in their system because both the payers use that claim edit system for their claims. That was my observation. Hopefully it can be resolved soon.
 
I was told today too that Anthem was reprocessing as of 3/24/23 and we didn't need to do anything at this time. Hopefully Aetna and Cigna will be soon, as well.
 
sbeall73 said:
We do not administer 90710 MMRV. We do not have that vaccine in our office. Our providers prefer to give MMR (90707) and Varicella (90716) separately. In the past two weeks, 3 insurances now have changed 90716 and 90707 to 90710 on our EOB's and paid our claims as a 90710 instead of paying them separately, as they have always done. I cannot find any research anywhere on this to explain why. When I call the insurances, they said "we are paying at the highest level of service". But this is not what we billed, or administered. Are any other pediatricians seeing this?
Click to expand...
We were told by BCBS to add modifier 59 to either 90707 or 90716. We are getting paid on both vaccines now when adding the 59 modifier. I would recommend submitting a test claim with modifier 59 on one of the vaccines.
 
sflvizcaya@hotmail.com said:
I was told by our home office that BC/BS had fixed the problem and would be reprocessing claims. Non the less, I messaged via Availity every claim that was denied and explained the situation. I have received payment on several of my January claims. However, they did pay the 90710 instead of the two separate immunizations which is a slightly higher payment.
Click to expand...
BCBS told us to add modifier 59 to one of the two procedures. We have been doing this and are getting paid on both vaccines.
 
We are now seeing this issue as well, Does anyone have deeper insight to Tricare East and rationale, or a process they have been successful at getting this resolved.
Cigna
We haven't seen Anthem BCBS doing this, but Is there something we are missing. We have never ordered MMRV and dont keep this vaccine in stock. I could understand if this were a LAB and the payer rebundled to the more comprehensive Lab, ex. Chlamydia and Gonorrhea Test.
Not only is it messing with reimbursement on the vaccines themselves, but they are also changing the Immunization Administration events that would correspond with billing the single vaccines 90707 and 90716 and turning the IA codes into the corresponding units for administering a MMRV vaccine.
Any additional insight or guidance, the reps have not been helpful.
 
We are seeing this with Aetna, Anthem, Cigna, and Tricare so far. I could not find anything where this change was announced.. Shouldn't the payers notify us when they want to make changes like this, that way we can plead our case on why this should not be done? The additional work they are causing all of us is just not right!
 
You ALL are definitely NOT alone with this issue! Cigna commercial has been denying both vaccines indicating that the payment is included with another similar service, but without even responding on EOB with 90710 and when called they just say their denial is because a similar service was paid, but obviously that is ridiculous since there is NO similar service to these two individual vaccines. SMH..do they even hear themselves when they say these things?
 
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