BACKGROUND:
Although three fourths of children under age three have been immunized in the United States, significant financial barriers exist in vaccine delivery that interfere with the achieving our nation’s immunization goals. The Centers for Disease Control and Prevention (CDC) reports that the majority of vaccines are administered in the private setting. Physicians are reimbursed for their services by reporting special billing codes known as CPT (Current Procedural Terminology©) codes to payers. Because of the variability and complexity of how these services are reimbursed to physicians, significant gains in vaccine delivery may be limited.

OBJECTIVE:
We reviewed the processes that make up the payment infrastructure, including the appropriate CPT codes reported, the method and results of valuation of these codes in the CMS Medicare Physician Fee Schedule (Resource Based Relative Value Scale or RBRVS), and the impact these values have on children’s services since the majority of commercial payers and state Medicaid Programs adopt the Medicare relative value unites (RVUs) in developing their own physician payment schedule.

METHOD:
We reviewed CPT for appropriate codes, and the Federal Register for physician payments on the RBRVS. AMA survey data that profiles the use of RBRVS by other payers was also obtained.

RESULT:
Our review reveals that the currently published values for vaccine administration omit payment for physician counseling of families about vaccines. Although this omission was made to help Medicare maintain its legislative mandate for budget neutrality, it impacts on children vaccine delivery by significantly undervaluing the payments other payers make to physicians who immunize children.

CONCLUSION:
The physician service of vaccine administration is currently undervalued, and corrections in the coding and reimbursement system are needed to improve immunization rates in children

LEARNING OBJECTIVES:
To understand the importance of reimbursement for vaccine delivery in the community office setting in achieving national immunization goals.