The National Correct Coding Initiative was created to prevent unbundling and the incorrect or inaccurate billing of a combination of codes. These are also called CCI edits. CMS identifies individual services that are components of a more inclusive service using the CCI edits.
One example of a CCI edit relates to the codes 90460 and 99401.
- 99401 - Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
- 90460 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
CPT code 99401 is not specific to counseling for COVID vaccines and because counseling is inclusive with code 90460, it is designated a CCI edit by CMS. Therefore, without a modifier to indicate a significant and separately identifiable service, such as modifier 25 to 99401, the CCI edit will link the counseling services as already built into the administration, per the code descriptor.
Billing a claim with a COVID diagnosis would not affect the CCI edit since diagnosis codes are not part of CMS' procedure to procedure (PTP) CCI edit.
Counseling is included in any vaccine administration, per code definition. If counseling is provided for COVID or any other vaccine, outside of a vaccine that was actually administered, we do consider that separate counseling reimbursable, but it must be appended with an appropriate modifier, such as 25 or 59, to indicate it is separate and distinct.
You may review our Commercial Reimbursement Policy here.
Code 99401 and 90460 Claim Denials and Next Steps
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) identified claims in which the two codes 99401 and 90460 were not billed with an appropriate modifier, and therefore were denied reimbursement. We have ceased any further recovery efforts with this CCI edit denial and will be re-processing any claims for those providers who have submitted partial or full recovery payments.
However, beginning August 24, 2022, the CCI edit for the code combination 90460/99401 will be effective. Please confirm that you are coding and billing your claims to accurately reflect the service you are providing.