CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Temporary COVID-19 Pediatric Vaccination Preventative Medicine Counseling Services for Commercial Members

Governs separate reimbursement for pediatric preventive medicine counseling (CPT 99401-CR) related to COVID-19 vaccination for commercial BCBSRI participating providers for members under 18. Specifies eligibility, billing rules, modifiers, POS, and cost-share waiver while the temporary policy is in effect.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTemporary COVID-19 Pediatric Vaccination Preventative Medicine Counseling Services for Commercial Members

Policy CodePolicy N/A

Change TypeTermination of temporary policy (effective for dates of service on or after July 10, 2023)

Effective DateNov 2, 2021

Next Review DateN/A

Key ActionInclude CPT 99401 with CR modifier in first modifier position and document time and specificity of counseling; no prior authorization required.

SourceLink

POLICY UPDATE CHANGES

Beginning with dates of service On Or after July 10, 2023, this policy will no longer be in effect and claims filed in accordance with this policy will not be separately reimbursed.

15 minmaximum counseling time per 99401

1 unitbilling limit per individual/patient or family event

CRmodifier required for separate reimbursement

POS 11/02

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Coverage Criteria

Coverage criteria for preventive counseling reimbursement

BCBSRI will separately reimburse preventive medicine counseling (CPT 99401-CR) for commercial participating providers under specific conditions and will waive member cost-share while the policy is in effect.

Applies to BCBSRI participating providers only for Commercial members under age 18 when counseling relates to COVID-19 vaccination and the vaccine is authorized/approved for pediatric use.

Provider type: reimbursable only when provided by credentialed pediatric primary care or family practice providers (MD/DO PCPs, NP/PCPs, PA/PCPs). Services provided by nurse care managers, RNs, LPNs, or other paraprofessionals are not separately reimbursable.

Service conditions: CPT 99401-CR may be billed only when the time and content of the counseling exceed typical vaccine education; 99401 is limited to up to 15 minutes. Separate reimbursement is limited to one unit per individual member or per family event when multiple family members are counseled; additional future counseling visits are not separately reimbursed under this policy.

Billing requirements: Claims must include CPT 99401 with the CR modifier in the first modifier position. For telemedicine/telephone services, use Place of Service (POS) 02 and report Modifier 95 for synchronous audio-video telemedicine; telephone-only claims must be filed with POS 02. Office visits use POS 11. Report an appropriate ICD-10 diagnosis; Z23 is acceptable for vaccine administration encounters.

Cost sharing: No member cost-sharing (deductibles, copayments, or coinsurance) will be imposed on covered COVID-19 preventive counseling services while the policy is in effect; this waiver may not apply to BlueCard host members or services provided outside the BCBSRI network.

Exclusions and service identification: This policy does not apply to group vaccination clinics established solely to provide vaccinations, and does not apply when preventive counseling is provided on the same day as preventive medicine service CPTs 99381-99384 or 99391-99394. When counseling multiple family members simultaneously, services must be separately identifiable for an individual; it is acceptable to file for one individual in such situations.

Documentation and audit: Medical records must document the time and specificity of the counseling. Modifier 25 is required if an E/M is separately identifiable and billed in addition to vaccine administration or 99401-CR. No prior authorization is required, but BCBSRI may review claims and audit records and may deny or retract payments if documentation is not provided upon request.

Termination: This temporary policy is effective through the emergency period; beginning with dates of service on or after July 10, 2023, the policy will no longer be in effect and claims filed in accordance with this policy will not be separately reimbursed. The policy may terminate 60 days after the State of Rhode Island emergency order ends or per BCBSRI determination.

Coding and Billing

Covered CPT CodesCPTCovered

99401

Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual, up to 15 minutes

Required modifier for separate reimbursement and cost-share waiverModifierCovered

CR	Catastrophe/Disaster related modifier required in first modifier position

Acceptable ICD-10 diagnosis codeICD-10Covered

Z23	Encounter for immunization

Telemedicine modifier and place of serviceModifier

Modifier 95

Synchronous telemedicine service via real-time interactive audio and video

Telemedicine place of servicemixed

POS 02

Telehealth: location where health services are provided or received through telehealth telecommunication technology (used for telemedicine and telephone-only claims)

Time threshold for 99401

Service time limitCPT 99401 is limited to counseling provided up to 15 minutes per visit.

When billableBill only when counseling time and content exceed typical vaccine education and standard vaccine risk/benefit counseling included with administration.

Billing frequencyBilled once (1 unit) per individual member and/or per family event when multiple pediatric patients are counseled simultaneously.

Provider restrictionsOnly credentialed pediatric primary care or family practice providers (MD/DO PCPs, NP/PCPs, PA/PCPs) may bill 99401; services by nurse care managers, RNs, LPNs, or paraprofessionals are not separately reimbursable.

Provider Actions and Documentation

Documentation Required

Prior authorization not required; document counseling time and specifics

No prior authorization is required for these preventive counseling services. Providers must document the counseling visit in the patient’s medical record, including the specific content of counseling and the time spent; all documentation must be made available to BCBSRI upon request. Failure to produce requested records may result in denial or retraction of payment.

No prior authorization required (PRIOR AUTHORIZATION: Not applicable).
Medical record must specifically outline time and specificity of the preventive medicine counseling services.
All documentation must be available to BCBSRI upon request; failure to produce requested information may result in denial or retraction of payment.

Denial Risk

BCBSRI routine claim reviews and right to audit

BCBSRI will perform routine reviews of claim submissions for compliance and reserves the right to audit medical records related to services provided. Providers should retain adequate documentation because audits may lead to denial or retraction of payment if records do not support the billed service.

Definitions and POS/Modifier Details

Catastrophe/Disaster modifier (CR) requirement

Modifier requirementCR modifier must be appended in the first modifier position on all claims for services to be considered separately reimbursed and to ensure no member cost share applies.

Other modifiersOther modifiers (e.g., modifier 95) may be reported in additional modifier fields but CR must remain in first position.

PurposeCR identifies Catastrophe/Disaster related services eligible for separate reimbursement and cost-share waiver under this temporary policy.

Telehealth place of service guidance

Allowed POS for telehealth/telephonePlace of Service (POS) 02 (Telehealth) must be used for telemedicine and telephone-only claims.

Telemedicine modifierModifier 95 should be used for synchronous telemedicine (real-time interactive audio and video) in addition to POS 02.