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New CPT Code Edits Could Worsen Already Low Adult Vaccine Uptake
FPs Report Payment for Immunization Administration Trumps E/M Services
By News Staff
In a Feb. 20 letter (2-page PDF; About PDFs) to NCCI Medical Director Niles Rosen, M.D., the AAFP said that family physicians already were reporting that some Medicaid plans and other payers were denying payment for E/M services based on the edits. "The reality is that the edit creates an extra barrier that practices must overcome while seeking proper payment for vaccine administration," said AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash.
- The AAFP recently called for the revocation of new CPT code edits initiated through the National Correct Coding Initiative.
- The edits in question allow insurers to pay the vaccine administration portion of a claim and reject payment for evaluation and management services.
- Such coding and payment complexities could lead to a decrease in adult vaccine administration, said the AAFP.
Stream added that the edit was "especially problematic" in the case of preventive medicine visits billed with CPT codes 99381 to 99397, during which vaccines most often are administered.
Stream acknowledged that on Feb. 1, CMS gave the nod to state Medicaid agencies to choose to "deactivate" the edit for the first quarter of 2013 retroactive to Jan. 1. As a result, the AAFP urged all states to promptly follow up with deactivation and then went a step further when it called on the NCCI "to revoke this particular edit altogether."
The same code edit issue was the focus of a Feb. 7 entry in Family Practice Management's "Getting Paid" blog. Blog author Kent Moore, the AAFP's senior strategist for physician payment, noted that the latest round of coding edits included about 300 changes that affect E/M services and vaccine administration.
Referring specifically to CPT codes between 90460 and 90474, Moore said that in each case, "the administration code trumps the E/M code" when it comes to which service Medicare and other insurers recognize for payment.
Moore updated the blog on Feb. 14 to reflect CMS' decision to allow state Medicaid agencies to deactivate the edit for the first quarter.
AAFP Protests CPT Code Edits