Pay attention, or don't get paid for E/M services performed with vaccinations (UPDATED)

Getting fully reimbursed for vaccinations is now requiring a little extra effort.

The latest round of edits for the Correct Coding Initiative (CCI) went into effect Jan. 1 and included around 300 changes that affect evaluation and management (E/M) services and immunization administration, specifically codes between 90460 and 90474.

In each edit, the administration code trumps the E/M code. That means if you bill a vaccine administration code and an E/M code for the same patient on the same date and do not append a modifier to the E/M code, Medicare and other payers who follow the CCI edits will only pay for the vaccine administration.

The idea behind the edits is that an E/M service provided at the same encounter as a vaccine administration should be a significant and separately identifiable service. Vaccine administration by itself does not merit both the administration code and an E/M code.

If, however, the situation merits separate reporting and you have supporting documentation, you can attach a modifier (such as modifier 25) to the E/M code and report both services. The one exception is E/M code 99211 (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician). CCI will not allow the addition of a modifier to report both 99211 and a vaccine administration. That edit is not new.

Both the American Academy of Family Physicians and American Academy of Pediatrics are protesting the new edits, saying they needlessly complicate physician billing practices and don't appear necessary under current CPT language.

They also worry that placing additional barriers to practices seeking proper payment for immunizations will lead to fewer people getting vaccinated. That's obviously a problem for both public and individual health and comes at a time when the Centers for Disease Control and Prevention has lamented the unacceptably low adult immunization rates in the United States.

Considering that the CCI is overseen by the Centers for Medicare & Medicaid Services, it appears once again that Uncle Sam’s right and left hands don’t know what each other are doing or that, even if they do, the consequences are just as disastrous.

2/14/13 UPDATE: CMS gives state Medicaid programs some leeway in following new vaccination E/M coding changes.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians