AAFP fires back on immunization coding edit

March 10, 2013

The American Academy of Family Physicians is objecting to a National Correct Coding Initiative edit that is denying payment for vaccine administration.

The American Academy of Family Physicians (AAFP) is objecting to a National Correct Coding Initiative (NCCI) edit that is denying payment for vaccine administration.

In a letter to NCCI, Glen Stream, MD, MBI, FAAFP, said, “The fact remains that this edit is needlessly complicated and unnecessarily confuses how physician practices bill and administer immunizations.”

The AAFP’s objection focuses on an NCCI edit, effective January 1, that denies payment for an evaluation and management (E/M) service billed on the same date to the same patient as a vaccine administration code, unless modifier 25 is appended to the E/M code. The change has resulted in denials by some Medicaid plans.

Although the Centers for Medicare and Medicaid Services issued guidance to states to permit Medicaid agencies to deactivate the edit for the first quarter of 2013, retroactive to January, Stream contends “the edit is especially problematic in the case of preventive medicine visits (99381–99397), during which vaccines are most-often administered.”

The AAFP adds that the edit creates an extra barrier practices must overcome to “seek proper payment for vaccine administration. The AAFP is concerned that this barrier will deteriorate vaccine coverage at the same time as the Centers for Disease Control and Prevention and others have lamented the unacceptably low adult immunization rates in the United States,” Stream adds.

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