90460 denial as dup but its not

efuhrmann

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We knew it was coming but now what do you do when 90460 is billed more than once on a date of service? Several carriers are saying it's a duplicate even though the diagnosis is different and the guidelines state to code this way. Modifier 59?? Does anyone follow the rules in this business? Or even read them(meant for the insurance carriers)???
 

halebill

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If you are having this problem, I would recommend reporting code 90460 x units, rather than on separate lines. Good luck. Unfortunately, every carrier is going to handle these the way THEY want to.

Bill Hale, CPC
 
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What I don't understand is why there are guidelines put into place regarding the 90460 & 90461 CPT codes but every carrier can decide how they want to process them. Isn't that why guidelines are put into place to begin with? It's too hard to keep up with what every insurance company wants and how they want it done. I know of only 1 insurance company that refuses to fix these codes, all of the others either process them correctly the first time or fix them when I call. Why can't they just all go by the guidelines that were put into place to begin with?
 

Jamster

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finding none of these work, adding units, adding mod 59. Can not get ins co to pay for more than one 90460 and 90461, it seems the ins co need to update their software to pay correctly. we've tried filing a claim with ins commissioner, no luck. anybody getting these paid?
 

DeeCPC

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You can not code more than one 90460 per DOS. "what do you do when 90460 is billed more than once on a date of service? Several carriers are saying it's a duplicate even though the diagnosis is different and the guidelines state to code this way. "

90460 =Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component

For each additional vaccine/toxoid code 90461=Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component

We code 90461 on one line x the quantity of vaccines ot toxoids.

BTW:
Using different diagnosis codes on the same CPT code for the same DOS does not make a difference.
 

halebill

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Uh oh, DeeCPC. That's incorrect. 90460 is reported for each 1st component. So, if you are administering three separate vaccines, 90460 is reported three times (or at 3 units) to represent the first component of each vaccine. All remaining components are reported with 90461. Example, patient receives:

90716 (1 component)
90698 (5 components)
90700 (3 components)

Report:

90460 x3 (for each 1st component)
90461 x6 (for additional components)

The payers here in South Carolina are screwy on this, too. They seem to be paying them as they had been all along when reporting 90471 & 90472's, with a maximum of three per service date.


Bill Hale, CPC
 

Jamster

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so we are all in agreement on the correct way to bill, but the ins co are not paying the correct way, despite our appeals and documentation on the correct way. whats the next step? getting the associations involved?
 

dragonflye

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Yea we had to some trouble at first and then we just started using the units, but we realize we have to break up our units on 90461 can only go up to x 5. just combine the units and put the right number according do your dx and if its a WCC you can use dx v20.2 for all shots/admin of shots too.
 

JodiLynn

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I have had the same issues @ our practice. Most payers are now processing my Inj codes as long as I put them in units @ the end of the claim w/the V20.2 dx. Now for the families that are splitting imms, it gets more complicated b/c it is not a WCC, its a imm only visit, so I have to code the dx for the imm w/the inj code. I alway get at least 1 90460 denied. A call to the ins co usually clears it up. The only companies that I am still having issues with is Cigna International & Humana. I have filed a complaint with the Insurance Com & they accepted and gave me a SR # and requested 5 examples ( I have over $5000.00 in injection codes alone for humana, as their members make up a bulk of our practice) and they are now in contact w/Humana and investigating them. Also, I filed a "Hassle Factor Form" with AAP. My suggestion is to do the same. Its very frustrating to open an EOB and see that denial, knowing it was coded correctly!!:eek:
 

ALEISHAB

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I think the confusion is coming from the description of the add on code 90461 that states "each additional vaccine or toxoid component administered". I think these code descriptions need to be revised again
 

MLWILLINGHAM

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JodiLynn we are fortunate that Florida has Prompt Payment laws that allow investigation of insurance companies that make their own edits, not every state is like Florida in these matters.
 

ollielooya

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Wow, after reading all these threads am wondering why the process has to be so complicated. "No, a cave-man CANNOT do this! Futhermore wearing the "expert" label but not being able to get this straightened out personally, continually keeps me in a state of confusion. It's somewhat comforting to know that I'm not alone. When will that "light" go on? Thanks for posting this thread and for keeping it active. Adding it to my huge list of favorites! ---Suzanne E. Byrum CPC
 
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