Wiki 25 modifier on E&M with immunization and administration codes

[fglanville@easthillmedical.com]

I am getting denials when billing a E&M such as 99213 with an immunization of 90677 and an administration code of 90471. The denial code of CO97 "benefit for services included in payment for another service that was adjudicated" ?
Any help on this. I have a 25 modifier on the E&M, do I not need one? the administration of the 90677 was paid however the actual vaccine was not??

 

[narredondo1103@gmail.com]

You may have a couple of issues happening here. Most insurances do want a modifier. First, do you have a medical dx on your e/m or just encounter for vacc? That could be one issue. Depending on the payer, they could have an exclusions policy that will not allow the 25 modifier to by pass. Sometimes you have to appeal the denial. Also, check with your payer to see if that particular vacc is a covered benefit.
Hope this help you.

 

[Sbatala@nacainc.org]

I am also running into a similar situation. BCBS AZ has paid the administration code 90471 however the actual vaccine, 90677, has been denied as CO 55 - Procedure/treatment/drug is deemed experimental/investigational by the payer. Were you able to get any answers or receive reimbursement for 90677?

I am getting denials when billing a E&M such as 99213 with an immunization of 90677 and an administration code of 90471. The denial code of CO97 "benefit for services included in payment for another service that was adjudicated" ?
Any help on this. I have a 25 modifier on the E&M, do I not need one? the administration of the 90677 was paid however the actual vaccine was not??

 

[fglanville@easthillmedical.com]

When billing 90677 for ages 19 thru 64 you need an additional DX code for underlying condition or risk factor that supports PT requiring a PCV20 vaccine. Examples would be chronic heart, liver or lung disease, Diabetes, cigarette smoking, solid organ transplant. You can refer to the attached link https://www.cms.gov/files/document/...ccinations-medicare-benefit-policy-manual.pdf