Wiki E/M and 90471 denying w/ mod 25 ?!?!

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anne32

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This one is pretty urgent! We are billing office visits w/ 90471 and modifier 25 and they are getting denied. We are billing the E/M because the patient was seen for more than just the vaccine (ex diabetes) We are receiving denials from Utah Medicaid, PCN, and Baby Your Baby so far... We have tried billing w. the mod 25 and also without the mod 25 and they will only pay on the E/M OR the 90471, but not both. Is anyone else having this issue? Are we billing this incorrectly? HELP!
 
oh those modifiers

'25' is the incorrect for the 90471. Remember, modifier '25' is for E/M. 90471 is not an E/M which would need modifier '59'
 
Since the 90471 is admistration of vaccine you cannot bill an E/M with mod 25, Mod 25 is appended only to E/M services if the physician is addressing any issue other than the reason for visit, lets say if the pjhysician is giving vaccine and at the same time if the physician address other issues not related to reason for the visit, then you can use E/M with mod 25 and a different diagnosis is not mandatory for E/M with 25.
 
These are state insurance carriers denying these procedures correct? If so, it's most likely they will not ever pay for both procedures no matter what modifier you attach. The facility I work for gets reimbursed at a set encounter rate meaning we can perform and bill out any number of procedures performed on a particular day for a particular patient, but we are only getting paid the set rate per the contract we have with our local Medicaid. You may want to contact your local Medicaid provider if you haven't already. I hope this is somewhat helpful.
 
Table 1. New Pediatric Immunization Administration Codes
CPT Code Description
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
90461 each additional vaccine/toxoid component
(List separately in addition to code for primary procedure.)
90471 Immunization administration (including percutaneous, subcutaneous, intramuscular, or jet
injections); one vaccine (single or combination vaccine/toxoid)
90472 each additional vaccine (single or combination vaccine/toxoid)
(List separately in addition to code for primary procedure.)
(Use code 90472 in conjunction with 90471.)
90473 Immunization administration by intranasal or oral route; one vaccine (single or combination
vaccine/toxoid)
90474 each additional vaccine (single or combination vaccine/toxoid)
(List separately in addition to code for primary procedure.)

You should not have to bill a 99213-25 in order to give a vaccination in addition to the evaluation. Ex:
99213 with dx 784.0 for headache.
then list the vaccine admin and vaccine with the appropriate dx code.

If this is still not allowed for some bizarre reason, then do vaccination clinics for catch up vaccines only. Once per month, have all the vaccine only patients come in and get them caught up...no sick visits, no well visits, just vaccinations only.
 
If any of the vaccines are thru Medicaid our state sc will no longer accept claims that are for vfc vaccines and shot admins that are not 90460 and 90461 also be sure that the zero dollar charges are populating on the claim most States are requiring the vaccine code and the vaccine admin to appear on claim under 18 would look like this 99213,25. Dx 250.*** 90460 90672,vfc DX v0481 also 90672 and 90686 were causing issues in sc but are starting to correct once we told them some final cpt codes were approved July and medicare also issued update 10-1 to some flu issues
 
Please tell me how to bill vaccine administration codes.
To report 90471, 90460 or 90473 & how many vaccine required to bill with modifier 59?
I know with office visit we can append modifier 25 to the office visit.


Sunil
CPC
 
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