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AAP advocacy leads to change in coding for vaccine administration :

December 30, 2016

AAP advocacy has led to an increase in the number of units of service allowed for vaccine administration.

The change affects code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) and code 90461 (immunization administration through 18 y via any route of admin, w/ counseling by physician or other qualified health care professional; each additional component).

Medically unlikely edits (MUEs) are the daily limit placed by the Centers for Medicare & Medicaid Services (CMS) and often are used by private payers to reduce the likelihood of coding errors. MUEs are part of the National Correct Coding Initiative (NCCI) edit system.

With the assistance of the Section on Administration and Practice Management (SOAPM) and the Committee on Coding and Nomenclature (COCN), the Academy submitted letters to Correct Coding Solutions, the CMS contractor for the NCCI. These letters contained clinical rationale for the increase in the number of MUEs for codes 90460 and the 90461.

CMS agreed with the Academy’s rationale, and the following updates will be made to the MUE database:

CPT code  Current MUEs Revised MUEs Effective date 
90460 6 9 April 1, 2017
90461 5 8 July 1, 2016 (Published Jan 1, 2017

CMS decided to increase the MUEs for CPT code 90461 retroactively to July 1, 2016, even though it was published on Jan 1, 2017. Denials based on MUEs for code 90461 after July 1 should be appealed.

CMS also states that if you bill Medicare for units of service greater than the MUE allows, you can appeal with appropriate documentation to support the excess, and Medicare may pay if deemed appropriate. The Academy encourages Medicaid and private payers to do the same.

The Academy also is asking several private payers to update their systems to reflect the change in MUEs and adhere to CMS’ effective dates. If you receive denials for MUEs, email the AAP coding hotline at aapcodinghotline@aap.org.

This advocacy effort was due to AAP members bringing issues to the attention of AAP staff and working together to make the changes that will benefit all members who immunize patients. Those who helped in the efforts include COCN members Margie C. Andreae, M.D., FAAP, and Joel F. Bradley, M.D., FAAP, and SOAPM members Suzanne K. Berman, M.D., FAAP, and Christoph R. Diasio, M.D., FAAP.

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