A Step-by-Step Guide to Auditing Pediatric Vaccine Administration Payments

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Vaccine administration is an important source of revenue for pediatric practices, but payment problems can easily go unnoticed when hundreds of vaccine claims are processed each month. Incorrect code selection, payer underpayments, missed administration charges, and claim denials can all reduce expected reimbursement. A regular audit can help pediatric groups identify these issues, recover missed revenue, and improve their billing process. Here is a step-by-step approach to auditing pediatric vaccine administration payments. Step 1: Review the Vaccine Administration Codes Start by reviewing the administration codes reported on vaccine claims. Pediatric practices commonly use codes such as 90460 and 90471 , but these codes have different reporting requirements. The billing team should verify that the administration code matches the service actually provided and that the documentation supports the code reported. For a detailed comparison, review Vaccine Admin Codes 90460 vs. 90471 in Ped...
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2022 Revised Codes for Principal Care Management

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In the Final Medicare Physician Fee Schedule (MPFS) for 2022 issued on November 2, 2021, the Centers for Medicare and Medicaid Services (CMS) added five new CPT codes in the categories of Chronic Care Management (CCM) and Principal Care Management (PCM) and increased reimbursement for already existing codes in the same categories. These codes are like chronic care management services in that the work involves the establishment, implementation, revision, and monitoring of a care plan for a patient. However, principal care management focuses on a single condition (rather than two or more). In the year 2022, Medicare will accept CPT codes 99424, 99425, 99426, and 99427, and discontinue HCPCS codes G2064 and G2065.

2022 Revised Codes for Principal Care Management

CPT 99424: Principal care management services, for a single high-risk disease, with the following, required elements:

  • one complex chronic condition expected to last at least 3 months, and that places the patient at 
  • significant risk of hospitalization, acute exacerbation/ decompensation, functional decline, or death, 
  • the condition requires development, monitoring, or revision of a disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities, 
  • ongoing communication and care coordination between relevant practitioners furnishing care. 

The first 30 minutes are provided personally by a physician or other qualified health care professional, per calendar month. The reimbursement rate for CPT 99424 in the year 2022 is $81. 

CPT 99425: For each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure. The reimbursement rate for CPT 99424 + 99425 in the year 2022 is $139.

CPT 99426: Principal care management services, for a single……. between relevant practitioners furnishing care. The first 30 minutes of clinical staff time are directed by the physician or other qualified health care professional, per calendar month. The reimbursement rate for CPT 99426 in the year 2022 is $61.

CPT 99427: For each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month (List separately in addition to code for primary procedure. The reimbursement rate for CPT 99426 + 99427 in the year 2022 is $108. Read Continue: 2022 Revised Codes for Principal Care Management

Location: United States

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