Wiki Can someone please clarify 90472

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dballard2004

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Can someone please clarify for me the correct use of CPT 90472? Do my understanding, this code is to be used for each addtional vaccine. Does this mean that if a patient presents for three vaccines, we would code:

Vaccine 1-90471 (plus vaccine)

Vaccine 2-90472 (plus vaccine)

Vaccine 3-90472 (plus vaccine)

or

is it only coded once regardless of the number of vacicnes given? Thanks.
 
Last edited:
That would be correct. They would also accept

90471
90472x2 with the DX for each additional code listed usually up to four.
 
It should be listed as
90471
90472
90472 - 59
Many offices I work with are getting either underpaid or denied for units out of range when coding with units. The 1500 billing manual states units must be 1 unless it is a timed service or items that are distributed as quantity like drugs. when the codes states each additional vaccince then each vaccine given is unique and distinc from the other so listing it with a 59 is the better way to communicate what was done.
 
The correct coding would be:

90471
90472 x# (however many additional IM immunizations administered).

The definition of 90472 states "each additional...list separately in addition to code for primary procedure". We do not have issues with any of our payers for the additional administrations and often it is more than 3 additional.

You would not want to list each individually as they will deny as duplicate. You should not use mod -59 (or -51) with an add-on code.
 
Add on codes are 51 exempt not all modifier exempt, and therefore you can use the 59 on an add on code. Some payers will pay with units but some do not and even those that pay some do not pay the correct amount. It is still in the billing manual as units great than 1 not allowed with the except as those that come as a quantity and each is not a quantity, the instructions state list separately. Therefore tha correct way is with the 59 modifier. Some denials and underpayments come with the explanation of units out of range which is why a lot of folks say the payers will only pay for a certain number.
 
mitchellde said:
Add on codes are 51 exempt not all modifier exempt, and therefore you can use the 59 on an add on code. Some payers will pay with units but some do not and even those that pay some do not pay the correct amount. It is still in the billing manual as units great than 1 not allowed with the except as those that come as a quantity and each is not a quantity, the instructions state list separately. Therefore tha correct way is with the 59 modifier. Some denials and underpayments come with the explanation of units out of range which is why a lot of folks say the payers will only pay for a certain number.
Click to expand...

What billing manual would this be located in? My experience is as stated in my previous post and we have not had any issues to my knowledge with reduced reimbursement on 90472 billed as "units". If you have the same number of immunizations as the number of administrations reported there should not be a quantity issue and if there is I would appeal. I respectfully disagree with the use of mod -59 on 90472.
 
Lisa,
we may just have to disagree, the 1500 has its own billing manual that has been continuously updated thru the years. Many times you may have read the statement but it is subtle and many people miss it. However I discovered it when we continued to be under paid and or denied when this was done, I did a ton of research and finally deciphered the statement. They use the language of quantity distribution and then do not clarify what this is referring to. I am sorry that you disagree but I maintain the 59 modifier is correct regardless of which method you wish to use. I know several will continue to use units. So we will just have to let it go at that.
 
mitchellde said:
Lisa,
we may just have to disagree, the 1500 has its own billing manual that has been continuously updated thru the years. Many times you may have read the statement but it is subtle and many people miss it. However I discovered it when we continued to be under paid and or denied when this was done, I did a ton of research and finally deciphered the statement. They use the language of quantity distribution and then do not clarify what this is referring to. I am sorry that you disagree but I maintain the 59 modifier is correct regardless of which method you wish to use. I know several will continue to use units. So we will just have to let it go at that.
Click to expand...

Agreed. We will just agree to disagree. :)
 
I do realize that this is an old post, and I hate open a can of worms here, but I feel the need to chime in. CPT Assistant, November 2000 states that code 90472 is to be reported one time for each addtional vaccine administered. I agree that modifier 59 should also be used on each addtional 90472 code.
 
I agree with the last poster. I am sitting here with a denial stating that the AMA defines CPT code 90472 as "...list separately in addition to code for primary procedure". They go on to state that "According to the MUE's, this code may be billed no more than 4 units per day for the same beneficiary." We billed 6 immunizations with 6 diagnoses and 90471 with 90472 X 5. Does anyone have a suggestion and I am not good at settling with the fact that we cannot bill the patient or we cannot expect to get paid for a service we performed and does anyone have a link to the MEU that states only 4 units per day allowed for the same beneficiary??:confused:
 
We've never billed more than 3 units of 90472 so I'm not sure what to suggest. MUEs are in place to help reduce claim errors. Since your claim is not in error, see if you can appeal with medical necessity.

The MUE is found here: CMS MUE LINK

It does list 4 units for 90472.
 
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