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

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disclosure richard h tuck md faap
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.
immunizations what s new for 2010
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!)
vaccines mission critical
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
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
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
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
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
IMPORTANCE OF ACCURATE APPROPRIATE IMMUNIZATION CODING
  • INCREASED REIMBURSEMENT
  • DECREASED LIABILITY
  • IMPROVED INFORMATION FLOW
vaccine coding specifics
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
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
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
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
  • -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
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
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
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
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)
vaccine administration 2005
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
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 administration24
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.

vaccine administration rvus for 2009
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
new code administration guidelines
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 guidelines27
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 guidelines28
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
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
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
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
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
? 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
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
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
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)
vaccine toxoid cpt codes
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
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

h1n1 influenza coding
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
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
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 - 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
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
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
e m visit codes sick visits
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
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)
best vaccine business practices
Best Vaccine Business Practices
  • Code Correctly
  • Contract with Knowledge
  • Purchase at the Best Price
business case for providing immunizations
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
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 vaccines52
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
slide53
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?

slide54
Contact derm–

MMR#1

Var#1

Hib#4

PCV#4

HepA#1

DTaP#4

LAIV

vaccine resources
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
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
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