Medicaid and PCV13

Medicaid and PCV13

As part of our efforts to keep you informed proactively of state-level developments in pediatric software, we wanted to alert you to a problem within some state Medicaid payment systems, like Texas and Pennsylvania, that is leading to claim denials.
The problem is simple to describe: Some state VFC systems have begun shipping PCV13 to fulfill pneumococcal vaccination needs. Unfortunately, some state Medicaid has not yet been able to load the appropriate CPT code into its payment system. As a result, the admin fees for the new vaccine are being denied, because they are associated with a vaccine that does not seem to be covered by the payment program.
Given the relatively small amounts of money involved in this problem, it is probably best to wait for the state to reprice your existing claims, rather than edit and resubmit at this time.
If you don’t want to wait that long to get paid for NEW claim submissions, OP offers a relatively simple interim solution: You can create a “block-and-substitute” rule for Medicaid payers that will swap the PCV13 CPT code (90670) to the allowable PCV7 code (90669).
Go to menu option Utilities->Manage Codes->Insurance Payers->Blocked and Substituted Codes. Click the [Add] button at the top of that screen to start setting up a new rule. First, select an Insurance Carrier associated with Medicaid. Then set the Blocked Code to 90670 and the Substitute Code to 90669. Next, set the Activation Date to the first date on which you received or administered PCV13. You should not need to add any modifiers or EPSDT information, so leave those fields blank. Press [Save], and you will return to the list of rules. If necessary, repeat for any other Insurance Carriers in your system that also point to Medicaid. For example, in Texas it is common to set up more than one payer due to their rules for distinguishing between sick and well care.
This new rule will go into effect immediately for any NEW superbills you process. Eventually you will need to retire this rule in Office Practicum, once Medicaid starts processing claims correctly. To do so, simply return to the Block and Substitute screen and set an Expiration Date.
Be aware that you should NOT use this workaround for private payers who are failing to pay for PCV13, because PCV13 is more expensive than PCV7 and reimburses at a higher rate. But since you don’t get paid for VFC vaccines, the substitution simply allows the admin fee to pay correctly.
Thank you for your ongoing use and support of Office Practicum, your Pediatric EMR. If you have any questions about implementing this change, please contact a member of our support team.