CPT changed by insurance company

We, as a pediatric practice, billed a flu shot for a child to Blue Shield with CPTs 90655 (shot) & 90465 (vac admin). Without our knowledge or permission, Blue Shield changed the admin code to G0008 and they paid it at a lower rate. Their allowed amount on 90465 is $18.02, and their allowed amount on G0008: $12.15. Are insurance companies allowed to change our coding as they see fit? Wouldn't G0008 be a Medicare accepted code?

CPT changed by insurance company

G0008 is a Medicare code. I have never seen an insurance company change any of our codes.

CPT code changed by insurance company

What a tricky thing to do. If you weren't watching, they'd have gotten away with it.

I'd call my provider rep. If you have to appeal these one by one, there isn't enough time in the world to do them. If the provider rep doesn't help, and your contract isn't specific, have your doctor write to the medical director.

CPT changed by insurance company

Tricky indeed! Provider rep stands behind their decision to change the code. I can understand denying a code if they don't feel it was coded correctly, but I have problems with them actually changing our codes. We had an issue with another big carrier down-coding our E&M visits and they eventually got popped with a class action suit.

Thanks for the suggestions. Hoping to get some resolution with them before flu season hits once again!

CPT changed by insurance company

Just a little note: I spoke with a representative at the Dept. of Managed Healthcare (who oversees all of Blue Shield's products) and per their analyst, insurance companies can indeed change/downcode as they see fit. I'm shocked!

90465

includes payment for direct physician counseling to the parent about the vaccine. I would guess that they noted that most docs counsel during an office visit so it is included in the E&M payment and the patient is not seen by the doctor when they come in just for a flu shot. So if a parent wants to talk to the doctor about the vaccine and there is no other reason for the visit, you should schedule a regualr appt, bill a 99212 with documentation from the physician about counseling and time spent.