Immunization Administration Coding Update for 90461

The AAP has received some emails concerning a new policy that was implemented by some payers  in relation to the Medically Unlikely Edit (MUE) for CPT code 90461. The per day MUE  edit was changed to 5. As soon as AAP staff and the Committee on Coding and Nomenclature  became aware of this, they worked with Correct Coding Solutions (CCS) to have this edit increased to a number that was more clinically appropriate. CCS (as the CMS contractor for the National Correct Coding Initiative) worked with CMS directly and they agreed the number should be increased.

Here is an excerpt from the letter from CCS:
CMS will increase the MUE value from five (5) to eight (8) for this code.  The new MUE value for this code will appear in the MUE version scheduled for January 1, 2017 and will be retroactive to the implementation date of…July 1, 2016.

Some AAP members have reported issues with the UnitedHealthcare (UHC) Maximum Frequency policy limit for CPT code 90461. The AAP is currently working with UHC  to resolve this and determine what their course of action will be in light of the change by CMS. If you have any other payers denying, please email the coding hotline