Denials for Preventive Medicine Codes Billed with Immunization Administration Services

Recent system updates resulted in NCCI edit denials (EOB 49270 – NCCI EDIT) of preventive medicine service codes submitted with EP modifier only and reported in conjunction with immunization administration service(s). These are accurate NCCI edit denials.

CMS billing guidelines indicate providers may use modifier 25 with modifier EP or modifier TJ for preventive medicine service codes (99381 – 99397 and additional screening codes 99406-99409 and 99420) when reported in conjunction with immunization administrative services (90460-99474). Providers may submit corrected replacement claims if appropriate.

Modifier 25 may be used with other non-preventive medicine evaluation and management (E/M) services when reported in conjunction with immunization administration when the E/M service is significant and separately identifiable. Exception: If a vaccine is billed with the same date of service as code 99211, National Correct Coding Initiative (NCCI) edits do not permit the E/M code to be reimbursed. CMS has stated that an E/M code should not be billed in addition to the administration code(s) when the beneficiary presents for vaccine(s) only.