Wiki 90460 coding dilemma requested by SC Medicaid Payors

[msonger]

As you know the new codes 90460/61 came into effect this past year. These new codes indicate counseling was provided by the provider/MD/NP. SC Medicaid released a memo stating that these new codes would be covered when billed with vaccinations. The other codes 90471 were reduced in payment since they only reflect the vaccination and NO counseling component. SC Medicaid payors have interpreted that for children 18 and under, we can only use codes 90460/61 to indicate vaccines were administered. I feel this is inappropriate coding and that I would be paid for a level of care that we did not provide. How do I appeal to this payor and their CPC that this is inappropriate. OR is it?

I am not coding the 90460 at this time and my 90471 codes are being rejected because they want me to send it as 90460.....see the below email correspondence....

Michelle, Here is the explanation from our coder in Charleston.



From: Hlavac, Carolyn
Sent: Thursday, August 25, 2011 9:09 AM
To: Steele, Kaye
Subject: RE: CPT 90460 vs. 90471 pediatric vaccine administration vs. counseling



The bulletin is for Medicaid FFS, not from Select Health. We are requiring that the RHC/FQHC bill with the vaccine and the appropriate admin codes for the VAFAC program and have required that since last year when DHHS began requiring the vaccine product be billed along with the administration code.



Our configuration is set that way as well. If they do not bill the vaccine product then they will not be paid for the vaccine administration. We questioned DHHS at the time this bulletin was released about the administration codes specifically and they told us that 90460-90461 were for use on children and 90471-90474 were to be used for adult vaccine administration. That is why there is a difference in the reimbursement. The 90471-90474 now reimburses the amount that 96372 reimbursed in 2010 for adult vaccine administration. It was $4 in 2010 for adult vaccine admin and with the reductions is now $3.72 as of 7/11/11. The counseling is not mentioned in any of the bulletins about this subject. The components are specifically mentioned and are not to be considered when utilizing these codes.



Thanks



Carolyn



From: Steele, Kaye
Sent: Wednesday, August 24, 2011 3:08 PM
To: Hlavac, Carolyn
Subject: FW: cpt 90460 vs 90471 pediatric vaccine administration vs counseling



Carolyn, Do you know what our interpretation is for FHQHC.



Kaye Steele

Network Management Representative

Select Health of South Carolina

803-359-6112 - office

803-348-5792 - cell

803-359-7177 - fax
www.selecthealthofsc.com
Mission: We help people get care, stay well and build healthy communities




--------------------------------------------------------------------------------

From: Michelle Newman-Songer [msonger@sumterfhc.com]
Sent: Wednesday, August 24, 2011 12:47 PM
To: Steele, Kaye; Michelle Newman-Songer
Cc: Michelle Newman-Songer; Debbie Prescott; Angie Windham
Subject: cpt 90460 vs 90471 pediatric vaccine administration vs counseling

Please know that this memo specifically states that it does not affect FQHCs.



90471 is still on the Medicaid fee schedule. My interpretation is that SC Medicaid's attempt was to notify providers that 90471 fee schedule was reduced since it did not include the verbal counseling. Also that in order to be eligible for the $12.61 a provider must provide the verbal counseling 90460/90461. In regards to the unit of service, my interpretation is that Medicaid is limiting it to one 90460 and two 90461 instead of per component as the cpt reads.



I have done some research on the AAPC website, and the certified coders agree that counseling must be done and documented to bill for it. Otherwise, admin only codes should be used 90471/72. I do not feel this memo indicates that Medicaid wants us to stop coding 90471 correctly. However, Medicaid is attempting to force providers to perform one on one counseling and document it to be paid for it with cpt 90460.



According to Medicaid fee schedule eff 7/1/11, here are the allowed amounts for these cpts:



90460 $12.61

90461 $12.61

90470 $3.88

90471 $3.72

90472 $3.72

90473 $3.72

90474 $3.72

 

[cubbiecatz]

They are incorrect in stating that 90460-90461 are the only codes for 18 and under. 90471 and other non-counseling codes are for EITHER, individuals over 18 or for individuals not receiving counseling. Keep fighting them on it.
We had to fight our local Medicaid to start paying for the new codes..they weren't aware of them!

Now that being said, are your doctors telling you they are not counseling the patients/parents about the vaccines? I would find it hard to believe they aren't educating them on the risks, etc. All we did was add a line to the vaccine record where the doctor can initial each vaccine component and we now bill the 90460-61 codes.

 

[GaPeach77]

I would be careful appealing the fact that counseling was not provided when giving vaccines since it is the law to give counseling. The providers are supposed to be aware of the immunization laws established by the CDC. Do a little more research before you put on paper in appeal to Medicaid that the providers are not following the law.

I have posted a link from the CDC about the Inform Law for Vaccines: Good Luch!

http://www.hhs.gov/nvpo/law.htm#A matter of law: Parents must be informed

 

[msonger]

Table of Contents



A matter of health: Immunization in the traditions of the U.S.
Controlling epidemics through vaccination laws
Controlling epidemics by preventing outbreaks of disease
A matter of law: Parents must be informed
Quarantine
School immunization laws
Adult immunization laws
Travel immunization laws
Globalization and international law
Immigration immunization laws
Immunization recommendations
Religious and philosophical exemptions



A matter of health: Immunization in the traditions of the U.S.

Immunization is vital to the health and survival of our nation. This concept has been recognized throughout American history. Health may have been one of the things Thomas Jefferson had in mind when he drafted the phrase, "life, liberty, and the pursuit of happiness" for the Declaration of Independence. Both Jefferson and Benjamin Franklin were scientists and innovators, and both were strong supporters of smallpox vaccination,(1) the only form of vaccination known to Americans at that time.

As with all of our laws, federal and state immunization laws are consistent with a basic tenet of American citizenship: The privileges of democracy, including individual freedoms, must be enjoyed in ways that do not interfere with or create risks for others. Immunization provides protection not only to the person immunized, but for many diseases, also to the people with whom the immunized person comes in contact. Immunization laws sometimes are changed as we gain new methods or understanding of disease control or new circumstances arise, but the basic truth about the responsibilities of citizenship does not change.

Table of contents
Controlling epidemics through vaccination laws

American courts have addressed many times the legal issue of whether government can compel vaccination, and have repeatedly supported immunizations. States have many laws that spell out what types of vaccinations people must have in various circumstances. We also have federal laws that specify the type of information that must be given to parents before a child is immunized. Under the National Childhood Vaccine Injury Act, section 2126 of the Public Health Service Act, all health care providers in the U.S. who administer any vaccine containing diphtheria, tetanus, pertussis, measles, mumps, rubella, or polio vaccine shall, prior to administration of each dose of the vaccine, provide a copy of the relevant vaccine informaiton materials that have been produced by the Centers for Disease Control and Prevention. Materials can be supplemented with visual presentations or oral explanations, where appropriate.(2)

Table of contents
Controlling epidemics by preventing outbreaks of disease

Public health officials do not rely on vaccines alone to control epidemics. To prevent the spread of disease, it is necessary to provide sanitary water and food supplies; education on hygiene, cleanliness, and disease prevention methods; and insect or animal management, as well as prevention of exposure to infected people through quarantine. Quarantine is isolation of persons with disease that can be easily spread, so that others will not be infected.

I read the link you provided...We are providing the paper that gives the immunization information that CDC provides. However, I do not interpret this resource to say that we have to verbally counsel on all the information provided on the form. Do you interpret the law to say parents must be verbally counseled?



Table of contents
A matter of law: Parents must be informed

The Centers for Disease Control and Prevention believes that parents should be fully informed about the risks and benefits of vaccination by talking to a trusted health care provider. By law, parents, guardians, or patients must be given information in writing about the risks and benefits of vaccination before a vaccine is administered. In fact, a recent national survey reconfirmed that parents overwhelmingly turn to their child's health care provider to obtain information or ask questions about vaccination.(3) If your health provider is not giving you the information you need, you can obtain copies by calling the CDC National Immunization Program information hotline at 1-800-232-2522 (English) or 1-800-232-0233 (Spanish), or view the information on the National Immunization Program's home page.

 

[msonger]

Table of Contents



A matter of health: Immunization in the traditions of the U.S.
Controlling epidemics through vaccination laws
Controlling epidemics by preventing outbreaks of disease
A matter of law: Parents must be informed
Quarantine
School immunization laws
Adult immunization laws
Travel immunization laws
Globalization and international law
Immigration immunization laws
Immunization recommendations
Religious and philosophical exemptions



A matter of health: Immunization in the traditions of the U.S.

Immunization is vital to the health and survival of our nation. This concept has been recognized throughout American history. Health may have been one of the things Thomas Jefferson had in mind when he drafted the phrase, "life, liberty, and the pursuit of happiness" for the Declaration of Independence. Both Jefferson and Benjamin Franklin were scientists and innovators, and both were strong supporters of smallpox vaccination,(1) the only form of vaccination known to Americans at that time.

As with all of our laws, federal and state immunization laws are consistent with a basic tenet of American citizenship: The privileges of democracy, including individual freedoms, must be enjoyed in ways that do not interfere with or create risks for others. Immunization provides protection not only to the person immunized, but for many diseases, also to the people with whom the immunized person comes in contact. Immunization laws sometimes are changed as we gain new methods or understanding of disease control or new circumstances arise, but the basic truth about the responsibilities of citizenship does not change.

Table of contents
Controlling epidemics through vaccination laws

American courts have addressed many times the legal issue of whether government can compel vaccination, and have repeatedly supported immunizations. States have many laws that spell out what types of vaccinations people must have in various circumstances. We also have federal laws that specify the type of information that must be given to parents before a child is immunized. Under the National Childhood Vaccine Injury Act, section 2126 of the Public Health Service Act, all health care providers in the U.S. who administer any vaccine containing diphtheria, tetanus, pertussis, measles, mumps, rubella, or polio vaccine shall, prior to administration of each dose of the vaccine, provide a copy of the relevant vaccine informaiton materials that have been produced by the Centers for Disease Control and Prevention. Materials can be supplemented with visual presentations or oral explanations, where appropriate.(2)

Table of contents
Controlling epidemics by preventing outbreaks of disease

Public health officials do not rely on vaccines alone to control epidemics. To prevent the spread of disease, it is necessary to provide sanitary water and food supplies; education on hygiene, cleanliness, and disease prevention methods; and insect or animal management, as well as prevention of exposure to infected people through quarantine. Quarantine is isolation of persons with disease that can be easily spread, so that others will not be infected.

I read the link you provided...We are providing the paper that gives the immunization information that CDC provides. However, I do not interpret this resource to say that we have to verbally counsel on all the information provided on the form. Do you interpret the law to say parents must be verbally counseled?



Table of contents
A matter of law: Parents must be informed

The Centers for Disease Control and Prevention believes that parents should be fully informed about the risks and benefits of vaccination by talking to a trusted health care provider. By law, parents, guardians, or patients must be given information in writing about the risks and benefits of vaccination before a vaccine is administered. In fact, a recent national survey reconfirmed that parents overwhelmingly turn to their child's health care provider to obtain information or ask questions about vaccination.(3) If your health provider is not giving you the information you need, you can obtain copies by calling the CDC National Immunization Program information hotline at 1-800-232-2522 (English) or 1-800-232-0233 (Spanish), or view the information on the National Immunization Program's home page.