By Betsy Priest, Coding Manager

Did you know?

You can bill for both an E/M with a vaccination code when the visit warrants it.  Guidelines are below:

  • the presenting problem or problems should be minimal
  • five minutes are spent performing or supervising services such as blood pressure checks
  • There needs to be a diagnosis other than the vaccine itself (Z code) – Rash, reason for vaccine, chronic conditions, etc.
  • These services do not need to be performed by an MD or midlevel, they can be performed by a nurse.

Modifier 25 must be appended to the service and submitted without the vaccine diagnosis code. If done by time it is a 5 minute visit.

If the patient is coming in strictly for an immunization, and there is no counseling or work up for any other issue or side effect, only the Immunization code should be submitted.

If you are counseling the patient on the immunization itself there are codes for the administration with counseling (they may reimburse at a higher level than the regular admin codes). The codes are: 90460 and 90461.

If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904 or


By Becky Amann, Compliance Manager


The Centers for Medicare and Medicaid Services (CMS) has recently reminded providers regarding their MLN publication pertaining to HIPAA Basics for Providers: Privacy, Security and Breach Notification Rules.

PF will be utilizing this document as part of our ongoing employee training regarding HIPAA.

This publication is located:

For Compliance questions, please contact Becky Amann at 716-348-3902 or



By Tammy Bartlett, Billing Manager


Modifications to YourCare’s professional fee schedule will take effect April 1, 2017.  The changes will apply to services rendered to YourCare Option, Child Health Plus and Essential Plan members.

YourCare Health Plan fees are calculated utilizing 2016 Medicare RBRVS methodologies and RVU tables with conversion factors for appropriate code sets.  Nurse Practitioners and Physician Assistants will be reimbursed at 85% of their supervising physician’s conversion factor for most services.

Anesthesia services utilize the prevailing based conversion factor multiplied by the Anesthesia Society of America (ASA) base anesthesia service units and subsequent time methodology.  Non anesthesia services will be reimbursed at the community based professional fee schedule.

The fee schedule will be available on their website at on or around April 1, 2017.

The latest referral and authorization requirements effective May 1, 2017 are also available on their website as listed above.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or