Payment Coding & Billing

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Payment, Co​ding, & Billing​



In addition to the vaccine product, offices should be appropriately paid for vaccine administration. The components covered by vaccine administration codes are separate from the product and overhead costs. Proper coding can also help to optimize payment.​

Payment for Vaccine Product

Appropriate payment for vaccine product expenses for the total direct and indirect costs must:

  • Be free of any discounts and based on a transparent and verifiable data source, such as the CDC vaccine price list for the private sector​.*
  • Cover the vaccine product purchase price as well as all related office expenses as noted above and a return on the investment for the dollars invested in vaccine inventory.
  • Be at least 125% of the current CDC vaccine price list for the private sector.
* Please note: The CDC does its best to keep this list updated with private sector costs; however, manufacturers are not obligated to provide private sector costs, so they may not be up-to-date.​

Payment for Vaccine Administration

Codes for the vaccine should be paired with a Current Procedural Terminology (CPT®) administration code to cover vaccine administration costs. These are also offered on the table of Commonly Administered Pediatric Vaccines. Login may be required.

Coding Resources

Negotiating for Payment

The AAP offers tips on negotiating strategies​ that may be helpful when contracting with payers.

For new vaccines on the market that have not yet had average prices calculated, pediatricians need to check with their carrier(s) to see how vaccine payments will be calculated. Some carriers may base payment on a percentage of billed charges. The AAP has developed "Vaccine Addendum to Payer Contracts" to address this situation and provide guidance when negotiating for vaccine payments. This document is available on the AAP Practice Transformation site. (Login may be required).

  • The AAP Managed Care Contract Issues may help pediatric offices understand issues with entering into a managed care contract. It offers tips on how pediatricians can negotiate payment for vaccinating within managed care contracts. 

Coding 99211

Some insurers may recognize CPT code 99211 for immunization-only visits by a nurse. However, there are specific rules on the appropriate use of this code. The AAP has a Position Paper (login required) on using 99211 with vaccine administration from which you can learn more.

Average Sales Price and Average Wholesale Price

Two other models exist: average sale price (ASP) and average wholesale price (AWP).

The AWP is the average manufacturer's price for a vaccine that is developed by various venders that is based on the vaccine price plus a 20% to 25% markup. Because of multiple AWP sources, pediatricians need to carefully review any payer's fee schedule using AWP. The ASP is based on vaccine manufacturers' quarterly sales reports. A concern with ASP is that it reflects discounts, many of which are not available to pediatric practices, thereby deflating the cost of the vaccine. These prices can lack transparency, and practices may want to insist that insurance contract language refers to the CDC vaccine price list as a basis for payment, with an additional clause that the vaccine fee schedules will be updated as soon as there is a price increase or at least quarterly.

CDC Vaccine Price List*

The CDC also maintains a Pediatric VFC Vaccine Price List​ that includes their current vaccine contract prices and the private sector vaccine prices for general information. Contract prices are those for CDC vaccine contracts that are established for the purchase of vaccines by immunization programs that receive CDC immunization grant funds (i.e., state health departments, certain large city immunization projects, and certain current and former U.S. territories). Private providers and private citizens cannot directly purchase vaccines through CDC contracts. The AAP believes that the CDC private payer vaccine price list should be used as a transparent methodologic basis for vaccine acquisition and invoice cost as part of the total cost of the vaccine.

* Please note: The CDC does its best to keep this list updated with private sector costs; however, manufacturers are not obligated to provide private sector costs, so they may not be up-to-date. 

Additional Resources

 Resources

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