CPT Code Edits Bungle Billing Process for Children's Vaccines

December 17, 2013 01:20 pm News Staff

Recently, the AAFP joined the American Academy of Pediatrics and a dozen other organizations to urge CMS to reverse a coding change that went into effect earlier this year that, according to the organizations, impedes children's access to care by discouraging physician participation in Medicaid.

[Child being examined by doctor in exam room]

Basically, the National Correct Coding Initiative (NCCI) edits make it difficult for physicians and other health care professionals to bill for administration of immunizations in conjunction with well-child visits.

In a Dec. 4 letter to HHS Secretary Kathleen Sebelius(3 page PDF), the organizations pointed out that the advancement of childhood immunizations is referred to by some as "our society's greatest health care achievement." The development and widespread use of vaccines has led to the eradication of childhood diseases that once were common, said the organizations. Furthermore, easy access to immunizations -- historically given at well-child visits -- undoubtedly played a role in those successes.

However, with the NCCI edits, CMS effectively undermined years of progress on the immunization front by severing the connection between well-child checkups and immunizations.

Story highlights
  • A CPT coding change implemented early in 2013 has made it difficult for physicians to bill for the administration of immunizations in conjunction with well-child visits.
  • In a letter to HHS, the AAFP and 13 other organizations urged HHS Secretary Kathleen Sebelius to deactivate the code edits before Jan. 1.
  • The organizations argued that the CPT code edits have led to claims denials and, ultimately, could impede children's access to health care by discouraging physician participation in Medicaid.

The NCCI edits apply to all evaluation and management services, including well-child visit CPT codes 99381 to 99395, when those codes are reported with immunization administration CPT codes 90460, 90461 and 90471 to 90474. The letter made it clear that confusion about the code edits -- including whether or not to use a "modifier 25" -- has led to the denial of many claims.

"Children's access to care has been seriously undercut by this ruling, and we respectfully request that you urge CMS to withdraw it," said the signing organizations.

Thus far, CMS has refused to deactivate the edits at the national level, said the letter, adding that the agency's decision to allow individual state Medicaid programs to temporarily deactivate the edits for 2013 has led to further coding confusion and concern.

The letter also noted that use of the modifier 25 -- the revised coding solution suggested by CMS -- was not only a gross misinterpretation of CMS' own rule governing use of a modifier but also likely would lead to expensive and time-consuming audits for already stressed physician offices. "Historically, the use of modifier 25 has been the leading trigger of Office of the Inspector General audits" and private payer audits, as well, argued the organizations.

"Because of the frequency with which child health care providers bill for immunization administration in conjunction with well-child checkups, if every claim involving both services requires modifier 25, the volume of modified claims would increase significantly, triggering numerous audits and exacerbating paperwork burdens," wrote the organizations.

Finally, the letter argued that the edits undermine an important goal of the Patient Protection and Affordable Care Act: namely, to improve physician payment for vaccine administration and other preventive services to encourage physicians' participation in the Medicaid program.

Congress recognized that low payment and the burden from the required paperwork deters full participation in Medicaid, said the letter. Adding an additional burden to practices and suggesting a solution that "vastly increases a care provider's chance of an audit" won't help achieve this goal.

The letter urged deactivation of the code edits no later than Jan. 1; however, as of Dec. 17, members of the coalition that signed onto the letter had not received a formal response from CMS.

This was not the first time the AAFP had pointed out flaws in these particular NCCI code edits. In a Feb. 25 letter to the NCCI medical director(2 page PDF), the AAFP expressed concern about the effect the edits could have on already low adult vaccine updates.

Related ANN Coverage
AAFP Successfully Argues to Retain CPT Code Edit for Newborn Care
Resubmit or Appeal Denied Claims After Oct. 1


New CPT Code Edits Could Worsen Already Low Adult Vaccine Uptake
FPs Report Payment for Immunization Administration Trumps E/M Services


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