Forum - Questions & Answers

Apr 15th, 2015 - pigaPLLC1   4 

Has anyone notice a change on payment for blue cross? 99391-99395 have not been getting paid when billed with vaccines. Does anyone know if it requires a modifier on office visit? never had a problem before until now. Thanks

Apr 17th, 2015 -

re: Has anyone notice a change on payment for blue cross? 99391-99395 have not been getting paid when billed with vaccines. Does anyone know if it requires a modifier on office visit? never had a problem before until now. Thanks

Vaccines have their own administation codes and should be billed together with the vaccine that is being administered. If you are doing a preventive med exam along w/the vaccines, you should be appending the modifier 25 to the preventive medicine exam. this information can be found in the back of the CPT® book under modifiers and the correct use of each one. its Appendix A on page 483 in the 2015 CPT® standard edition.

Apr 17th, 2015 - petunia 195 

re: Has anyone notice a change on payment for blue cross? 99391-99395 have not been getting paid when billed with vaccines. Does anyone know if it requires a modifier on office visit? never had a problem before until now. Thanks

Here's a statement for the Americam Academy of Pediatrics adressing the issue.
On January 1, 2013 the Centers for Medicare and Medicaid Services (CMS) released the latest version of the National Correct Coding Initiative (NCCI) edits. The NCCI edits are code edits published by both Medicaid and Medicare to support correct coding and claims adjudication. Included in the new Medicaid and Medicare edits were edits on all evaluation and management (E/M) services that disallow patient with immunization administration codes without the proper modifier. The modifier indicator for all these edits is a "1," meaning that with proper modifier placement, the edit can be overridden.

While the Academy is urgently working with National Correct Coding Solutions - the CMS contractor for NCCI edits - to have the edits suspended on all preventive medicine service codes (99381-99385 and 99391-99395) with all immunization administration codes (90460 and 90461, 90471-90474). It should be noted that the edits are currently locked in and will continue to be in effect for Medicaid, Medicare, and private payers that implement CMS coding policies until such time that AAP advocacy efforts are successful. Over the past several days, the AAP has been in telephone contact with the highest levels of the CMS contractor responsible for the NCCI edits and has delivered a formal letter demanding retraction of these edits.

Therefore, effective immediately and for all claims submitted after January 1, 2013, AAP urges its members to append modifier 25 to the preventive medicine service code (99381-99395) when it is reported in conjunction with any immunization administration service (90460-90461; 90471-90474).

A modifier 25 should also be appended to other non-preventive medicine E/M services (eg, 99201-99215) when reported in conjunction with immunization administration -- but only when the E/M service is significant and separately identifiable.

We understand this is an administrative burden for you and your staff. The AAP is working diligently to unlock this change and will forward additional information on this issue as it becomes available.

Apr 17th, 2015 - pigaPLLC1   4 

re: Has anyone notice a change on payment for blue cross? 99391-99395 have not been getting paid when billed with vaccines. Does anyone know if it requires a modifier on office visit? never had a problem before until now. Thanks

thanks for the information, in this past several months and year 99391-99395 have been billed with no modifier and have been getting paid until now. Thanks again for the detail information, I really appreciate it!



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