New CPT Code Edits Could Worsen Already Low Adult Vaccine Uptake

FPs Report Payment for Immunization Administration Trumps E/M Services

February 25, 2013 04:30 pm News Staff

The AAFP spoke out recently against CPT code edits initiated through the National Correct Coding Initiative (NCCI)( because the edits could affect patient access to immunizations.

[Denied-Medical Claim]

The edits in question went into effect on Jan. 1 and effectively allow insurers to deny payment for evaluation and management (E/M) services when those services are billed on the same day and to the same patient as a vaccine administration code unless a "modifier 25" is appended to the E/M code.

In a Feb. 20 letter(2 page PDF) 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.

story highlights

  • 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.

"The AAFP is concerned that this barrier will deteriorate vaccine coverage at the same time (that) the Centers for Disease Control and Prevention and others have lamented the unacceptably low adult immunization rates in the United States. The latest version of NCCI seems to be working at cross purposes in this regard … and deters physicians from administering vaccines to their patients. This edit is needlessly complicated and unnecessarily confuses how physician practices bill and administer immunizations."

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.