Imms Admin (90465 vs. 90471)

For some time, we have known that our customers who use the “new” imms admin codes tend to get paid better for them. We figure, just as Dr. Bradley stated at the PCC-sponsored Coding event in NYC recently, that many of the MCOs simply entered the new codes with the new values but didn’t update the original codes with the new values.
Wait – unless you know exactly what I’m talking about, that won’t make sense. In 2005, CMS introduced the new vaccine admin codes – 90465/90466 (there are others, but these are the doozies). At the same time, they more-or-less doubled the RVU value of all the standard admin codes. We’re talking about going from <$10 to >$20. It’s a big deal and PCC has many customers getting the new, higher rates. Plus, it’s proper coding.
So, even though we still meet and work with practices who don’t yet use the new codes – no joke – we have plenty of information that indicates that using the new codes pays off.
Recently, the AAP asked us to look into this issue (and the “-25 modifier” issue, the results of which will follow). Here is some data you simply will not see anywhere else. Sure, some folks have it, but no one else will share. We will, because this is important. So, for 2006, here’s what PCC clients did:

CPT Average
90465 $28.47 $13.07 136% 62%
90466 $21.91 $8.87 194% 79%
90467 $24.09 $9.11 178% 67%
90468 $21.91 $8.14 210% 78%
90471 $24.73 $10.61 118% 50%
90472 $18.83 $7.16 167% 63%
90473 $23.17 $7.46 168% 54%
90474 $17.03 $6.71 178% 70%

There you have it – the average reimbursement for PCC’s customers across the country for a 90465 is 62% of Medicare vs. 50% for the 90471. Or, on average, $3 a pop. If you’re not using the new codes – and setting your prices properly – then you are losing money. Lots of it.
Oh, yes – I am ignoring that “62% of Medicare” bit. It makes my stomach turn.

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