Coding for THSTEPS- help!

csruiz

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I am having trouble getting paid for the 90471 and 90472 codes from Community First Medicaid. I am coding these with DX v20.2 and then following with the V codes for each vaccine that was administered. ex. v20.2, v06.1, v03.81 etc. I am getting paid by TMHP but not by Community First. I contacted the person who is the representative for the medicaid physicals for Community First but he tells me the reason they are not being paid is because I am following the v20.2 with these vaccine codes. That only the
v20.2 should be listed. Also, he is telling me I should not be using the 25 modifier it should be used only for "acute care". I believe he is totally incorrect. When I showed him how TMHP is paying me he says that "this is their logic" on coding. I thought coding was a standard thing and not what one insurance makes up. Can someone give me some input? I have been coding for 3 years and have not encountered this.
 

Anna Weaver

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insurance

Unfortunately, nothing is standard with insurance. I have found that each carrier decides what they want and will make you conform in order to get paid. Doesn't make it right, just is.
 

csruiz

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Modifier 25 is not just for acute care though right? I am suppose to use it even for physicals?
 

Anna Weaver

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mod 25

Again, that is payer specific. Some want the 25 on any E/M with another procedure no matter what the procedure is. Other's do not want the 25 on anything. Still other's do not want them on the preventive visits and some only with certain procedures. Sorry, I can't give you a definitive answer on this.
 
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