Wiki BCBS and Aetna bundling 90480

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laurie@pediatricassociates.net

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BCBS and Aetna are bundling CPT code 90480 (COVID vaccine administration) when billed with COVID vaccine codes 91321 or 91322 AND a flu vaccine (90656) with vaccine admin code 90460. If we bill if we bill 90480 and 91321 (or 22) alone, the 90480 is paid. This bundling issue just started in October. Is anyone else experiencing this issue?
 
Are they seeing it as two admin codes bumping up against each other on the same date? Have you checked the provider news and provider resources, or Availity, clear claim connection, etc. for changes? You should always sign up for the provider newsletters and updates from the big plans to keep up with changes. There was probably a change announced for 10/1/25.
I think I have seen where some plans (depending on Commercial, Medicaid/VFC) don't want 90480 if the pt. is under 19 y/o. They want 90460 with a modifier (if counseling was done and documented). Therefore, if you did the two, separate vaccines (with the face to face counseling) on the same date, and that was their policy, you would have to use two 90460 possibly. Either that or they might be looking for a 59 or XS to show it was two separate vaccines for 90480, 90460.
 
amyjph said:
Are they seeing it as two admin codes bumping up against each other on the same date? Have you checked the provider news and provider resources, or Availity, clear claim connection, etc. for changes? You should always sign up for the provider newsletters and updates from the big plans to keep up with changes. There was probably a change announced for 10/1/25.
I think I have seen where some plans (depending on Commercial, Medicaid/VFC) don't want 90480 if the pt. is under 19 y/o. They want 90460 with a modifier (if counseling was done and documented). Therefore, if you did the two, separate vaccines (with the face to face counseling) on the same date, and that was their policy, you would have to use two 90460 possibly. Either that or they might be looking for a 59 or XS to show it was two separate vaccines for 90480, 90460.
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I reviewed the provider bulletins for both Aetna and BCBS for the last several months and I didn't find anything related to this issue. I also tried the clear claim connection and it indicated that the claims should pay. We are going to try the 59 modifier and see what happens.
 
We are seeing this issue in pediatrics, 90480 is bundling with 90471 if not billed with modifier 59 appended to 90480. we are also seeing bundling of the well exam (99391-5) if 59 is not put on 90480. Anthem's policy went into effect 10/1/25 if you are looking for the info
 
Hi all! We are using the modifier 59 when the following are done- 90656, 90471, 91321, and the 90480*59. So far most of our payers (commercial and state) like this. However, today I'm getting denials for Providence Health Plan. Of course the guidance is slim to none. Is anyone else experiencing this, with this particular payer, or have any other recent updates?

I see that CMS revised the original NCCI rule for Medicaid. But those codes are not the above mentioned: https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits
 
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