CODING 2001 by pengxiuhui

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									Immunization Coding
        2010
 The Basics and Beyond
 Richard H. Tuck, MD, FAAP
                         Disclosure
               Richard 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.
             IMMUNIZATIONS
           What’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!)
    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
  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 !
          Immunization Benefits
 Benefits for patients
 Benefits for practice
  – Practice entry point
     »Reason for regular preventive medicine visits
     »School entry requirements
     »College entry requirements
           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
                   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
IMPORTANCE OF ACCURATE APPROPRIATE
       IMMUNIZATION CODING


    INCREASED REIMBURSEMENT

    DECREASED LIABILITY

    IMPROVED INFORMATION FLOW
        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
           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
             Immunization
Evaluation and Management CPT Codes

   Office Visit
     – New             (99201-99205)
     – Established     (99211-99215)
   Preventive Medicine Visit
     – New             (99381-33385)
     – Established     (99391-99395)
     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
                 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
        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
          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
    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
             EXISTING CPT CODES 2004
Vaccine Administration

   90471        Immunization administration (includes percutaneous,
    intradermal, subcutaneous, or intramuscular injections); one vaccine
    (single or combination vaccine/toxoid)

   90472       each 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)

   90474       each additional vaccine (single or combination
    vaccine/toxoid) (List separately in addition to code for primary
    procedure)
    Vaccine Administration 2005
 Relative Value in RBRVS includes
  Physician Work component
 Requires Physician counseling
  (and documentation)
 Patient much be < 8 years old
            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)
       CPT Codes for Vaccine Administration

                                        Injectable       Oral/Intranasal
                                          Vaccine              Vaccine

        Patient <8 yrs of age
                                          90465                90467
        AND physician
        face-to-face counseling           90466                90468

                                          90471                90473
           All other situations
                                          90472                90474

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.
            Vaccine Administration
               RVUs for 2009
   Values - Existing codes
             RVU 2009 medicare    RVU 2009 medicare
    – 90471 – 0.58/ $20.92   90472 – 0.29/ $10.46
    – 90473 – 0.38/ $13.71   90474 – 0.25/ $ 9.02
   Values - New codes
    – 90465 – 0.58/ $20.92   90466 – 0.29/ $10.46
    - 90467 -0.38/ $13.71    90468 – 0.28/ $10.10
      Ohio VFC payment $5.00 → $10.00
       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)
    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
     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
     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
     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
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
    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
    ? 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
 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
    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
                  2011
    Immunization 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)
           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
                  CPT 2010
                Vaccines/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
           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
    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)
           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
                 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
             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
              E/M Visit Codes
           Health 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
              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)
                  E/M Visit Codes
               Immunization-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)
Best Vaccine Business Practices

   Code Correctly
   Contract with Knowledge
   Purchase at the Best Price
      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
        Business Case - Vaccines
   Reimbursement should cover
    – Vaccine Product
       »Price of the product
       »Shipping and handling
       »Excise tax
       »Storage
       »Inventory Management
       »Loss
       »Insurance
       »Tracking claims
         Business Case - Vaccines
   American Academy of Pediatrics
    estimates:
     – Losses/waste ~ 5%
        »Patients change their mind
        »Excess stock (influenza)
        »Office losses
        »Expired vaccines
     – Payment should be 17–28% over cost
       In addition to administration payment
                       Case
A 2-year old child with private insurance is seen in
  September for a contact dermatitis. He has not
  been seen since 9 months of age and you
  administer the following vaccines: MMR#1,
  Var#1, Hib#4, PCV#4, HepA#1, DTaP#4 and
  LAIV. A future well visit is scheduled for one
  month later before the patient leaves the office.
How would you code this encounter?
          CPT      # description         ICD     descrip
          99213-25 1 E/M visit           692.9   Dermatitis
Contact   90707    1 MMR                 v06.4   need for…
  derm–
          90716    1 Varicella           v05.4   need for…
MMR#1
          90648    1 Hib                 v03.81 need for…
Var#1
          90669    1 PCV                 v03.82 need for…
Hib#4
          90633    1 HepA                v05.3   need for…
PCV#4
HepA#1    90700    1 DTaP                v06.1   need for…
DTaP#4    90660    1 LAIV                v04.81 need for…
LAIV      90471    1 1st vacc, inj       v06.1   need for…
          90472    5 Each add’l inj      v…      need for…
          90474    1 Each add’l oral/nasal v04.89 need for…
  DOCUMENT !
 DOCUMENT !
DOCUMENT !
         Vaccine Resources

 CDC  – www.cdc.gov/nip
 AAP – www.aap.org MOC
 Immunization Action Coalition –
  www.immunize.org
 SanofiPasteur – “Library” –
  www.vaccineshoppe.com
          Reference Documents
 AAP Vaccine Coding Table 2010
 AAP Business Case for Vaccine Products
 AAP Red Book Vaccine Pipeline 2007
 CDC-ACIP Vaccine Recommendations 2010
  www.cdc.gov/nip/acip
 Vaccine Information Sheets (VIS)
  www.immunize.org
 SanofiPasteur website
  www.vaccineshoppe.com
    AAP Your CODING CONNECTION
     Coding & Reimbursement Resources
 National AAP Coding Hotline:
  aapcodinghotline@aap.org ; free service
  to members and their office staff
 Coding publications: Coding for
  Pediatrics, Pediatric Coding Companion,
  Quick Reference Guides, ICD-9-CM
  Flipchart, RBRVS Brochure, AAP News
  Coding Corner

								
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