Question code pairs found to be unbundled

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Can someone explain why i am getting this denial im linking the annual with the vaccine as well when i called the insurace they are saying the 99391 should not be billed with 90460 but arent we suppose to bill the vaccines with the admin code 90460 and 90461 for peds?

4603
 

SharonCollachi

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Clovis, CA
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904609939120130101*1CPT Manual or CMS manual coding instructions
904609939220130101*1CPT Manual or CMS manual coding instructions
904609939320130101*1CPT Manual or CMS manual coding instructions
904609939420130101*1CPT Manual or CMS manual coding instructions

NCCI shows above. I read in another location that with a -25 modifier, the vaccines would be bundled into the preventive visit.
 

skrug888

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I always add the -25 to the OV and use the routine exam dx. Then Z23 on the vaccines. Is this Medicaid? I ask because of the SL on the 90460.
 

SharonCollachi

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I was just looking at the New York Medicaid manual. That manual does also say to use modifier 25 on the visit code.

NCCI editing will allow payment for an office visit (E&M and preventative medicine codes) and a vaccine administration service billed on the same day of service if the office visit meets a higher complexity level of care than a service represented by CPT code 99211. For payment to be made for both services, the office visit must be billed with Modifier-25. Providers must maintain documentation in the medical record to support use of an appropriate modifier.


Do you have the manual or access to it? It is here (click me).

Also, wayyyyyyyy back in the day, when I was in primary care and we were using VFC, we billed the vaccine itself with $1. For anyone not familiar with VFC, "Vaccines for Children", it's free vaccine supplied by the state. This was a quick clue-in that we expected zero dollars for it, and if it was accidentally paid, we would refund it immediately.
 
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