In January of 2011, immunization administration CPT codes changed. The administration w/ counseling codes that pediatricians used previously (90465-90468) became invalid for billing. Two new codes (90460 and 90461) replaced them, and the replacement includes a change in the coding method, from per-shot to per-antigen.
This help article will teach you how to use the new codes, suggest some helpful configuration changes to Partner, and provide some examples for how you to bill immunizations in Partner after January 1st, 2011.
We recommend that you share this information with anyone in your office who posts charges or who is responsible for coding a visit.
Here When You Need Us: PCC has studied this issue carefully and would be happy to talk with you about the coding changes and how they will effect your checkout procedure and claim submission. Send a message to firstname.lastname@example.org or call us at 1-800-722-1082 to talk about your office’s needs. You can fill out a support request form for specific help with this issue.
SnapCodes Can Help: PCC designed SnapCodes, a charge posting tool for Patient Checkout (checkout), to help users quickly post the correct codes for a given circumstance. SnapCodes make it easier to calculate the correct administration codes for a procedure. Read below for more information.
Overview: What are administration codes, and which ones are changing?
When you bill an immunization procedure, such as a 90707 for an MMR, you should also bill one or more immunization administration codes. If you provide a basic level of immunization counseling and provide an opportunity for questions, then you should be billing administration codes that include counseling. Prior to 2011, counseling had to be by an M.D. to qualify. After January 1st, counseling can be by any medical professional.
Before January 1st, 90465 and 90468 indicated immunization administrations with counseling. After January 1st, 2011, you will need to use the new codes, 90460 and 90461, as described below.
Administration codes without counseling have not changed. If you provide shots and do not talk to your patients about the immunizations, then you can continue to use 90471-90474.
Age Matters: Before 2011, there was a cut-off date of 8 years for the 90465-90468 codes. The new code rules apply to all children under 19 years, so many offices will no longer have to worry about age restrictions for most immunization administration codes. Check your 2011 CPT coding guide for more details.
Billing With the New Codes
The new coding guidelines say that administration coding should reflect the number of diseases immunized against as well as the number of shots. The work and the responsibility of administering a vaccine is now measured by both the antigens and the supplies, personnel, and other expenses inherent to the task.
Coding a Shot
For every immunization injection a patient receives, with counseling by a qualified medical professional, you should bill the correct immunization procedure code (90476-90749) and a single unit of 90460. When a single shot immunizes against multiple diseases, such as in the case of MMR, DTaP, Comvax, Pentacel, or any other combination vaccine, you should bill an additional 90461 for each antigen.
If you administer a Rotavirus vaccine to a patient and provide counseling, you should bill 90680 for the immunization, followed by 90460 for the administration. If you administer an MMR, you should bill 90707, 90460, and two units of 90461. If you administer the new Pentacel vaccine, you should bill 90698, 90460, and four units of 90461.
|Vaccine||Included Antigens||What to Bill (w/ Counseling)|
What to Bill (No Counseling)
Transition Concerns and Other Codes
Before January 1st, you may wish to make changes in Partner and train your office staff about the new coding rules. Posting a visit will take extra time as you calculate the correct codes, and your billing staff may need practice. These code changes require that your billers and those who administer vaccines understand how many additional antigens are represented in combination vaccines. You can make changes to Partner that will help, as described in the sections below.
Your office can handle this transition in your own way: Your provider may make notes on the encounter form, your checkout desk may need to learn how to count up antigens and select the correct procedures, or your biller may be in charge of calculating admin codes when posting charges later.
Immunizations Without Counseling: As mentioned above, if your office administers immunizations and does not talk to the patient or family about the immunizations, you can continue to use 90471- 90474 for administration codes.
For more information, you can read the AAP’s FAQ, which explains the new codes and provides several useful examples.
Use Partner Snap Codes
PCC’s Snap Codes is a tool for creating procedure and diagnosis posting bundles.
After your office configures a Snap Code, such as “MMR w/ Counseling”, you can select it during checkout and have all the required codes (90707, 90460, and two units of 90461) fill-in automatically on the screen, for your approval.
Are Insurance Carriers Ready for the New Codes?
Experienced billers know that it takes a while for some insurance carriers to begin reimbursing properly for new codes. The new codes become part of the CPT standard on January 1st, which means carriers are not allowed to reject claims with the new codes. However, they may reimburse at $0.00, request more information, or have other problems implementing the new codes.
PCC will stay on top of how carriers are responding to the new codes, but there will almost certainly be a period of transition as carriers play catch-up.
Non-Compliant Carriers: If a carrier requests that you use the old, outdated codes, PCC recommends that you ask for that request in writing.
Partner Configuration Changes
You can make a number of configuration changes to Partner that may ease the transition to the 2011 immunization administration codes. Review the options below and contact PCC Support for help.
Want Help?: Contact PCC Support at email@example.com or 1-800-722-1082 for help configuring your immunization administration.
Add the New Codes to Your Procedure Table
You must add the two new immunization administration codes to your Partner Procedures table. The two new entries in ted will look like this:
For information on using the Table Editor (ted), read Editing Partner Tables.
Do Not Overwrite Old Codes: Even though 90460 and 90461 replace some previous administration codes, you should not edit and overwrite those table entries in Partner. The old codes are an important part of your billing history, and changing them would change each patient’s billing record.
Pricing: PCC estimates that the 2011 Medicare values for 90460 and 90461 will be in the neighborhood of $17-$25 and $9-$12 respectively. The prices shown in the image above are only a sample and do not reflect pricing recommendations.
Optional: Add Antigen Indicator to Immunization Procedure Names
Whoever enters charges in Partner will need to add administration codes based on the number of antigens in a shot. Your provider might do the work themselves and note it on an encounter form, but your checkout staff or billers may also need to figure out the admin codes later, after the visit. To help them, you can edit your immunization names to indicate the total number of antigens.
Consult PCC Support: If you decide to change your procedure names, contact PCC Support (800-722-1082, firstname.lastname@example.org) and tell them about the change. We will check your immunization and charge screen configuration to ensure that immunizations will still track correctly to patient records.
Run the Table Editor (ted), select the Procedures table, find an immunization, and add the number of antigens to the procedure name. For an MMR vaccine, which would need a 90460 and two units of 90461, you might name your procedure “MMR (3)”.
For more information on using the table editor, read Editing Partner Tables.
Optional: Create Snap Codes for Each Immunization
You can create Snap Codes for sets of procedures and diagnoses. Then, when you post the Snap Code in the checkout program, the correct procedures and diagnoses will pop into place on the screen.
First, create the Snap Codes in the Table Editor (ted). For example, you could create an “MMR w/ Counseling” Snap Code that would contain the following:
Then, train your office to use the Snap Codes during charge posting.
Names that Work For You: Some offices are naming their Snap Codes by code, for example “c90707” for an MMR with counseling. Other offices invent their own short names. You can create Snap Code names that will work best for your office’s posting style.
Optional: Update Your Encounter Forms
Partner generates custom encounter forms for every visit, and those encounter forms may be specialized for different visit reasons and different providers. Once your providers and billing staff decide how to indicate the immunization administration billing needs, you may want to edit your encounter forms to help the provider pass down the information to the checkout and billing staff.
Contact PCC Support for help editing your encounter forms.
Optional: Update Your Charge Screens with New Codes or Snap Codes
During checkout and charge posting, Partner brings up a custom list of diagnoses and procedures. For a Well Visit, for example, Partner brings up typical procedures, often based on the aged visit reason, in order to help the biller select the correct procedures.
You may decide to edit your charge screens to include the new administration codes, or a Snap Code that can trigger the new codes. Contact PCC Support for help editing charge screens.
Use Allowables to Make autopip and pip Flag Bad Payments
You can use PCC’s Contract Fee Schedule Editor to enter an expected reimbursement for the new codes. That way, if an insurance company reimburses $0.00, charges will not autopost and/or you will see an error in pip.
For more information, read the Contract Fee Schedule Editor help articles.
How You Will Post
Once you have added the new procedure codes to Partner, and made other optional configuration changes, your staff can post the new procedures during checkout. (You can read more about posting charges in the Checkout section of our online help.)
During the crucial step of entering charges, a typical 5 Year Well Visit might look like this:
As described in the section above, each immunization receives both its own code, a 90460, and a total number of additional antigens for 90461. That means that for both DTaP and MMR, there are two units of 90461.
What About Units?: In the example above, the user is posting separate 90460 and 90461 charges for each immunization. That is the official suggestion of the AAP at the time of this documentation’s publication. If PCC discovers that insurance carriers will accept grouped units for all 90460 and 90461 procedures in a visit, the above screen would look more like this:
In the above example, units are grouped. Each immunization receives a 90460, and a total of four additional units of 90461 account for the additional antigens in DTaP and MMR.
Are Inscos Properly Reimbursing?
Immunizations are an important revenue source for pediatric offices, and PCC recommends you keep a close eye on administration code reimbursement over the next several months. As insurance carriers begin receiving and responding to the new codes, they will make mistakes and require follow-up.
Autopost Drops Unusual Adjustments to the Manual Report
If an insurance carrier decides to adjust off the new procedure codes, and their Claim Adjustment Reason Code is not 24 or 45, then Partner’s autopost program will drop the ERA to the Manual Report for your review.
Allowables: Watch for the Expected Payment
If you set up contract fee schedules in Partner, as mentioned above, then underpayments will be dropped to the Manual Post report during auto-posting of ERAs. When posting payments manually in pip, underpayments are visible while posting.
Insurance Reimbursement Analysis
You can run the Insurance Reimbursement Analysis report (ira) and display reimbursement for selected procedures (90460, 90461). That can show you any insurance group that is not reimbursing.
Contact PCC Support for help finding a report or creating a custom report to help you track problematic carriers.