Wiki pediatric immunization administration billing instructions

[galaniz5404]

has anyone been incountering problems getting reimbursed for the new immunization codes effective 1/1/2011 to include requesting reimbursement for each additional component

 

[btadlock1]

I feel your pain!

has anyone been incountering problems getting reimbursed for the new immunization codes effective 1/1/2011 to include requesting reimbursement for each additional component

More than you can imagine - everybody wants them billed differently, and some still won't pay for all of them. I've been blasting payers with appeals, including copies of CPT manuals. Here's an example of the appeal letter I have for it - if you happen to live in Texas, you can even use it!

Patient:
Policy#
Provider Account #
Date of Service:
Billing NPI/Tax ID:

Appeal​

On the date of service mentioned above, the patient was seen for a routine child well check, and also received immunizations per the CDC's recommendations.

Per CPT 2011, vaccine administration codes 90460 and 90461 have been added to replace the expired codes, 90465, 90466, 90467, and 90468.
CPT 90460's code description states "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's description states "each additional vaccine/toxoid component (List separately in addition to code for primary procedure)"

Under the new vaccine administration guidelines, providers now report 90460 for every vaccine/toxoid administered, and for combination vaccines, 90461 is reported for each additional component in the combined vaccine product. The guidelines clearly state that each 90460 is reported separately; no modifiers are required. In fact, examples given in the Expert Edition of AMA's CPT 2011 (attached) clearly indicate that 90460 should be reported as many times as necessary, using separate lines for each unit, without appending any type of modifier. The add-on code 90461 is only used to report additional components of combination vaccines; not the act of physically administering additional vaccine products. Also, both codes are to be reported independently from any evaluation and management services performed during the same encounter.

Please review your claim adjudication system and make the necessary changes to comply with the new coding guidelines. Erroneous denials for duplicate charges, 'unrecognized' CPT codes, or denials based on inappropriate bundling logic should be reprocessed immediately for payment. Any subsequent denials for this claim without written disclosure of your rationale enclosed, will be treated as a violation of Title 28 of the Texas Administrative Code, pursuant to sections: §21.2807, §21.2815, §21.2822, and §21.2810, and will be forwarded to the Texas Department of Insurance for further investigation. Please contact me at the number provided below if you need any additional information. Thank you.

Brandi Tadlock, CPC, CPC-P, CPMA

 

[galaniz5404]

thanks for your help