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Immunization Coding 2010 The Basics and Beyond

Immunization Coding 2010 The Basics and Beyond. Richard H. Tuck, MD, FAAP. Disclosure Richard H. Tuck, MD, FAAP.

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Immunization Coding 2010 The Basics and Beyond

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  1. Immunization Coding 2010The Basics and Beyond Richard H. Tuck, MD, FAAP

  2. DisclosureRichard H. Tuck, MD, FAAP • I have financial relationships or interests with proprietary entities producing health care goods or services related to the content of this CME activity. I am Consulting Editor of Pediatric Coding Alert for Eli Health Care. I serve on the speakers bureau for Sanofi Pasteur. • My content will not include discussion/reference of any commercial products or services. • I do not intend to discuss an unapproved/investigative use of commercial products/devices.

  3. IMMUNIZATIONSWhat’s New for 2010? • PRODUCTS- FDA Approval ACIP-CDC-AAP Adoption VFC Adoption • CODES - New CPT/ICD Codes • VALUE - RBRVS – New RVU’s and CF • PAYER PAYMENT Adoption of Vaccine Products, Timing, Payment • PATIENTS- Covered Benefits, Copays, Deductibles • CONTRACTS- Captitated Plans (Carve out Immunizations!)

  4. Vaccines – Mission Critical ! • THE KEY preventive mission for primary care physicians • Evidence Based • Maintains the Public Health • Explosion in vaccine products • Child born in 2010 will receive over 50 vaccinations prior to adulthood

  5. Vaccines – No Margin, No Mission ! The challenge: Maintaining a vaccine delivery system Requires both Clinical and Business Skills A physician with 50 newborns per year could give 2000 vaccines (>$90,000 potential cost) Vaccines are now the second largest practice expense (non universal states) The Margin must support the Mission - It can be financially profitable !

  6. Immunization Benefits • Benefits for patients • Benefits for practice • Practice entry point • Reason for regular preventive medicine visits • School entry requirements • College entry requirements

  7. Reimbursement Keys • Coding is Easy • Payment is complex, but payers are improving • Contracting is key • Group Purchasing is available • Understanding VFC requirements is important • Checking remittance advice (EOB) is critical

  8. Objectives Coding for Vaccines and Toxoids • To assure appropriate reimbursement for services • To meet reporting requirements • Immunization Registries • Vaccine Distribution Programs • To code for Evaluation and Management Services in addition to immunization codes • To understand CPT and ICD immunization coding

  9. IMPORTANCE OF ACCURATE APPROPRIATE IMMUNIZATION CODING • INCREASED REIMBURSEMENT • DECREASED LIABILITY • IMPROVED INFORMATION FLOW

  10. Vaccine Coding Specifics • Each vaccine has a specific CPT code AMA identifies vaccines pending FDA approval ~ code assigned • Each vaccine has an appropriate ICD-9 diagnosis code • Each vaccine should be linked to an individual IA (immunization administration) code

  11. Immunization Coding Summary • Bill and Document ALL: • E/M Visit • Office Visit, Preventive Medicine • Immunization Administration • 90471 – 90474 • 90465 - 90468 (2005 Peds specific) • Vaccine/Toxoid • 90476 – 90749 • Link to ICD Diagnoses V20.2 Well Child CSHCN Diagnosis + Specific Vaccine V Codes

  12. Immunization Evaluation and Management CPT Codes • Office Visit • New (99201-99205) • Established (99211-99215) • Preventive Medicine Visit • New (99381-33385) • Established (99391-99395)

  13. Preventive Medicine Services • 99381 - 99395 • E/M services performed in the absence of a significant problem/abnormality • Do not include office procedures, ancillary services, and immunizations

  14. 25 Modifier • -25 Modifier Distinct and separate E/M service provided at the time of another E/M service or procedure • Not required by CPT for immunizations, but may be required by specific payers for payment

  15. 99211 Nurse Immunizations • Bill 99211 in addition to immunization administration codes (90471 – 90474) if : • Nurse provides health evaluation prior to the immunization (Medically Necessary E/M service) • Include vital signs (temperature, weight) • Document ! • Triggers a copay • If immunization only, with no E/M services, bill administration and product codes only

  16. CPT Codes for Vaccine Administration • Reimburse for all expenses related to vaccine delivery other than product purchase • For VFC vaccine, there is a maximum administration fee (varies by state) – OHIO $14.67 • Choice of specific CPT code depends on: • Whether first or subsequent vaccine that day • Whether injected or given orally/intranasally • Whether patient is <8 yrs of age AND physician provides face-to-face counseling • Report an administration code for each vaccine given *See AAP document “The Business Case for Pricing Vaccines and Immunization Administration” www.cispimmunize.org

  17. Billing for Vaccine Administration • Reimbursement for administration should cover • Needle and syringe • Nurse work in administration • Gloves. Exam table paper, Band-aid, Gauze • Required reporting • Immunization registry input • Does not include physician counseling • Does not include other E/M services

  18. EXISTING CPT CODES 2004 Vaccine Administration • 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) • 90472each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) • 90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) • 90474each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

  19. Vaccine Administration 2005 • Relative Value in RBRVS includes Physician Work component • Requires Physician counseling (and documentation) • Patient much be < 8 years old

  20. 2005 “NEW” CPT CODES Vaccine Administration • 90465 Immunization administration under 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day • 90466 each additional injection (single or combination vaccine/toxoid), per day • 90467 Immunization administration under age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day • 90468 each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)

  21. CPT Codes for Vaccine Administration Underlined CPT codes can only be used for the first vaccine administered of any kind. The non-underlined codes indicate each subsequent vaccine administered. Only one of the underlined codes may be used per day.

  22. Vaccine AdministrationRVUs for 2009 • Values - Existing codes RVU 2009 medicare RVU 2009 medicare • 90471– 0.58/ $20.9290472– 0.29/ $10.46 • 90473 –0.38/ $13.71 90474 –0.25/ $ 9.02 • Values - New codes • 90465– 0.58/ $20.9290466– 0.29/ $10.46 • 90467 -0.38/ $13.71 90468 –0.28/ $10.10 Ohio VFC payment $5.00 → $10.00

  23. New Code Administration Guidelines • One initial administration code per visit • Example: 2 month infant receiving immunizations • 90465 - initial injection (Dtap/IPV/HIB) • 90466 X 2 – subsequent 2 injections (Prevnar, Hep B) • 90468 – subsequent oral vaccine (Rotavirus) • Always make first administration the injection (higher relative value than oral vaccine)

  24. New Code Administration Guidelines • Physician counseling (face-to-face) apply only for new codes (90465-90468) • ? Immunization administration code to use with 99211 nurse only immunization visit (<8 years) • 90471 - 90474 • ? Need for physician face-to-face counseling at each visit for boosters

  25. New Code Administration Guidelines • Can advanced practice nurses (APNs) report 90465-90468 if providing counseling? • Yes, if within state-licensed scope of practice • Can a nurse report 90465-90468 as “incident to” the physician? • No, require physicians do the counseling

  26. Immunization Administration • If a significant separately identifiable E/M service (eg. Office, preventive medicine, other outpatient) is performed, the appropriate E/M service code should be reported in addition to the vaccine/toxoid administration codes. • -25 modifier with E/M code not required by CPT, However, may be required by some payers

  27. Preventive Medicine Ancillary Services Screening RVU/ 2009 Medicare Hearing testing - Select picture 92583 .91/ $31.30 Hearing testing – Puretone 92551 .29/ $10.46 Hearing testing – Puretone(threshold) 92552 .59/ $21.28 Vision screening 99173 .07/ $2.52 Developmental Screening 96110 .36/ $12.98 Lab Hemoglobin 85018 .10/ $3.45 Urine (dip only) 81002 .08/ $2.78 Routine Venipuncture 36415 .26/ $9.17 Finger/Heel Stick 36416 .15/ $5.25 Immunizations Immunization administration 90471/90465 .58/ $20.92 90472/90466 .29/ $10.46 Vaccine/Toxoid product 90476-90479 Other Injection/other 96372 .58/ $20.17

  28. New Vaccine Counseling Payment Issues • Payment for extensive additional counseling time related to increased parent concerns • Payment for time spent counseling when vaccines refused • Payment for additional counseling when parents insist vaccines spaced out beyond recommended schedule

  29. Time Based Extensive Counseling • Coding Option 99401-99404 with Preventive Medicine Codes Counseling in 15 minute increments • Code based on Time for Office Visit Codes Over 50% face to face visit time spent counseling • 99212 – 10 minutes • 99213 - 15 minutes • 99214 – 25 minutes -25 modifier on E/M office visit code

  30. ? Alternate Vaccine Schedules ? • Additional visits can justify a 99211-25 charge if nurse provides distinct E/M work discussing parent concerns If physician face to face discussion: ≥ 99212-25 based on time • Additional initial vaccine administration charges will result in overall increased charges to the patient for extended schedules However, there is increased practice expense

  31. Multiple Component Vaccine Issues • Pros • Fewer injections for children • Less nurse work/practice expense • Documented improved compliance with AAP recommended vaccine schedules (5%) • Cons • Parent concerns with multiple antigen vaccines • Loss in Immunization Administration payments

  32. Multiple Antigen Vaccine Solutions • New Immunization Administration Codes • Current AAP COCN initiative • Based on number of antigens in vaccines • Increased payer payment for multiple antigen vaccines • Potential win/win • Humana – Additional $14 for multiple antigen vaccines • United – Additional product payment for Pentacel (List price plus 20% + $10) • Wellpoint- Additional product payment 7/1/10 • Positive medicaid (VFC) precedents in other states

  33. 2011Immunization Administration Codes • 2011 New Immunization Administration Codes • Old IA code sets will be deleted (90471-90474; 90465-90468) • New IA codes based on number of components in a vaccine • 1 Component (IPV, Influenza) • 2-4 Components (MMRV, Tdap) • ≥5 Components (Dtap-IPV-HIB)

  34. Vaccine/Toxoid CPT Codes • CPT codes developed to meet reporting requirements • 90476 – 90749 • Identify the specific vaccine product only • CPT differentiates vaccines with different • Conjugate material • Mode of administration • Age indication (usually dosing difference) • Preservative • Use in addition to administration codes

  35. CPT 2010Vaccines/Toxoids • Term “preservative free” includes products containing either very little or no preservatives • 90669 revised • Pneumococcal vaccine – 7 valent • 90670 • Pneumococcal vaccine – 13 valent • 90378 • Respiratory Syncytial Virus – monoclonal antibody, recombinant, 50 mg each +96372 Injection code

  36. H1N1 Influenza Coding • CPT • 90470 - H1N1 IA, any route, including counseling $24 • 90465-90468, 90471-90472 – if directed by plan • G9141- H1N1 IA, any route, including counseling Ohio Medicare $19.95 • ICD • 90663 – Influenza vaccine, pandemic formulation • G9142 –Influenza A vaccine (H1N1), any route administration • $0 vs. $0.01 charge

  37. H1N1 Influenza Testing Coding • Rapid Influenza testing • If testing for two distinct virus strains (A & B) Report test for rapid influenza test twice 87804 87804-59 (distinct procedure modifier)

  38. Vaccine ICD Coding • Link CPT to ICD coding • E/M to ICD code • Office Visit to appropriate ICD diagnosis • Preventive Medicine to V code V 20.2 (routine infant or child health check) • Vaccine specific CPT code to Vaccine specific ICD V code

  39. V - Codes • V 04.0 to V 06.9 Vaccines • V06.1 Dtap • V04.0 IPV • V03.81 HIB • V06.4 MMR • V05.4 Varivax

  40. ICD Changes for 2006 • V64.00 Vaccination not carried out • V64.01 Acute illness • V64.02 Chronic illness • V64.03 Immune compromised state • V64.04 Allergy to vaccine • V64.05 Caregiver refusal • V64.06 Patient refusal • V64.07 Religious reasons • V64.08 Had disease being vaccinated against

  41. E/M Visit CodesHealth Supervision Visits • CPT • Preventive E/M Codes (99381-99397) • Vaccine Product Codes • Vaccine Administration Codes • ICD • Health supervision of infant/child (v20.2) • USE ONLY IN CONJUNCTION WITH A PREVENTIVE CPT Code • Vaccine specific ICD Codes

  42. E/M Visit Codes Sick Visits • CPT • Office/outpatient E/M Codes (99201-99215) • Payers may require modifier –25 be appended to E/M visit code • Vaccine Product Codes • Vaccine Administration Codes • ICD • Link E/M Code to the ICD reason for visit – (eg, otitis media 382.0) • Link each Vaccine Product/Administration CPT code to a separate ICD code: • Vaccine specific V code • “need for prophylactic vaccination…” (eg, DTP v06.1) • DO NOT USE v20.2 (health supervision)

  43. E/M Visit CodesImmunization-Only Visit • CPT • No E/M code • 99211 only if medically necessary separate E/M service • Vaccine Product Codes • Vaccine Administration Codes • ICD • Link each Vaccine Product /Administration CPT code to a separate ICD code: • Vaccine specific V code • “need for prophylactic vaccination…” (eg, DTP v06.1) • DO NOT USE v20.2 (health supervision)

  44. Best Vaccine Business Practices • Code Correctly • Contract with Knowledge • Purchase at the Best Price

  45. Business Case For Providing Immunizations • Cost of providing vaccines • $ tied up in inventory • No profit over product cost • Potential loss with poor payments • Determining practice expenses related to providing vaccines • VFC/ Medicaid FFS/Managed Care confusion • The mission vs business sense

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