90465 Debate Revisited

I have some very interesting continued news about TriCare and I've had a piece about Main Street Vaccines building for a week or two, now, but I have to address this issue first.

Earlier this year, I wrote about how there is a measureable difference between the payments for a 90465/90471 and 90466/90472.  Although $1.50 to $2.50 a procedure doesn't seem like much, when you do 10,000 of them, it adds up.  Especially for pediatricians.

So why are there still so many pediatricians who don't even use the proper immunization administration code?!  Ignore, for a moment, the fact that not using a 90465 properly is bad coding practice.  Ignore, for a moment, that you are failing to document with your code that you spent time counseling.  You are losing money.

How often should a practice be billing the 90465 vs. a 90471?  It's difficult to know for sure - what percentage of the kids you immunize are under 8 years old?  Is even a modicum of imms counseling part of your clinical protocol?  Some of our clients insist that they "never" do counseling except for the first in a series of shots.  I not only think that they are factually wrong, but if they were right, they'd be missing an important clinical opportunity.

I don't know the answer, but I have a feeling that most pediatric practices ought to be doing as many, or more, 90465s and 90471s.  Just a gut instinct.  In reality, though, practices are all over the map.  I could simply give you the averages of everything, but the variance is so large, I think it would be worthless.  Let me show you...

...below, I took a random sampling of PCC clients and grouped them into segments based on their ratios of 90465:90471 procedures.  Then mapped them out.  So, on the left side of the graph below (click on it to zoom in) are practices who do very few - sometimes none! - 90465 procedures.  On the other end, you'll find practices who do more 90465s than 90471s - you'll see that some do 4-5-7x more.


I won't judge who is right and wrong...ok, I take that back.  I'll bet that the overwhelming majority of practices who have a 90465:90471 ratio under 75% are mis-coding and losing money.  Under 50%? Under 25%?  And these are PCC clients, they are supposed to be better.I can't understand it.

Anyone want to help explain this to me?  Do you really not do any physician imms  counseling in your office, and why not?