Coding for Childhood Immunizations - 2013 Update for Pediatric Offices-

1. Coding for Childhood Immunizations -2013 Update for Pediatric Offices-

2. Developed by: Georgia Chapter American Academy of Pediatrics Content Author: Linda Edwards, RN, CPC

3. EPIC programs are produced in cooperation with: Georgia Immunization Program Georgia Academy of Family Physicians Georgia Chapter- American College of Physicians (Internal Medicine) Georgia OB-Gyn Society With support from: Georgia Immunization Program Merck & SanofiPasteur

4. Disclosure This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA or unapproved or “off-label” uses of pharmaceuticals or devices. In accordance with ACCME Standards, I am required to disclose any real or apparent conflict(s) of interest to the content of this presentation.  I would like to disclose the following:

5. Goals & Objectives • Understand Current Procedural Terminology (CPT®) and International Classification of Diseases, 9th Revision, Clinical Modifications (ICD-9-CM) codes and conventions for reporting immunization services • Improve coding accuracy • Obtain appropriate payment for immunization services

6. Components of Immunization Services • The vaccine product • Practice costs • The administration • Physician work • Practice expense • Professional liability

7. Immunization Administration Physician Work • Vaccine counseling services • Evaluating potential contraindications • Reviewing/discussing the CDC Vaccine Information Sheet(s) • Reviewing/discussing risks and benefits of vaccine(s) • Discussing particular diseases for which immunization is needed • Obtaining consent for each vaccine(s) • Addressing related concerns and questions

8. Immunization Administration Practice Expenses • Administrative duties - Making appointment - Preparing & filing medical record • Clinical duties - Routine vital signs, administration, documentation, observing patient • Supplies & equipment costs: - Medical supplies - Equipment - Vaccine Information Sheets (VIS)

9. Coding the Vaccine Product • CPT codes 90476-90749 used to report the vaccine/toxoid product only • Codes are specific to product manufacturer and brand, specific schedule (number of doses or timing), chemical formulation, dosage, age guidelines and/or route of administration

10. Coding the Vaccine Product Report the exact vaccine product administered • 90700 (Diphtheria, tetanus toxoids, and acellular pertussis [DTaP], younger than 7 years, for IM use) versus 90715 (Tetanus, diphtheria and acellular pertussis vaccine [Tdap], 7 years or older, for IM use) • 90655 (Influenza, trivalent, split virus, preserv free, 6-35 mo, IM) versus 90657 (Influenza, trivalent, split virus, 6-35 mo, IM)

11. Immunization Administration (IA) • Includes 2 families of codes: • Codes 90460 and 90461 • Codes 90471 – 90474

12. Immunization Administration

13. Qualified Healthcare Professional(QHCP) Defined From CPT 2013: A “physician or other qualified healthcare professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

14. Reporting Guidelines 90460 and 90461 • Code 90460 is reported for the 1st or only component of vaccine(s) administered on a day of service • single or combination vaccine • Code 90461 reported in addition to 90460 for each additional component in a combination vaccine “component” = eachantigen in a vaccine that prevents disease(s) caused by one organism; conjugates or adjuvants are not considered to be components combination vaccines = vaccines that contain multiple vaccine components (antigens)

15. Vaccine Components

16. Reporting Guidelines 90460 and 90461 • Reported in addition to the vaccine/toxoid code(s) 90476–90749 • Codes 90460 and 90461 do not differentiate routes of administration or “first” versus “each additional” administration • Age designation (through age 18) is consistent with the age requirements under the VFC program

17. Reporting Guidelines 90460 and 90461 • Physician or qualified healthcare professional (eg, non-physicians if allowed under state scope of practice and bill independently) mustprovide face-to-facevaccine counseling for the patient/family (patient age 18 or under) on the day the vaccine is administered • Medical record documentation mustsupport that physician or other qualified health care professional personally provided the vaccine counseling (each component/antigen) • Georgia Medicaid does not use 90461 for VFC vaccine administration

18. Reporting Guidelines 90471-90474 • Codes 90471-90474 are reported when physician or other QHCP does notperform the vaccine counseling to the patient/family or does notdocument that counseling was personally performed • When patient is 19 years of age or older

19. CPT Codes 90471-90474

20. Reporting Guidelines 90471-90474 • Reported in addition to the vaccine/toxoid code(s) 90476–90749 • Report immunization administration for each vaccine administered • Onlyone“first” immunization administration (90471 or 90473) code is reported per day of service • “First” vaccine can be reported from either route of administration • Georgia Medicaid accepts these vaccine administration codes

21. Putting the Rules into Practice A 4-year-old established patient receives diphtheria, tetanus, acellular pertussis, andpolio virus (DTaP-IPV) vaccine (90696), measles, mumps, rubella and varicella (MMRV) vaccine (90710), and pneumococcal conjugate vaccine (90670) at his preventive medicine visit The physician counsels the parent on all vaccines, discusses risk associated with each disease, and benefits of… What would you report?

22. 4 Year Old - Immunizations 90696DTaP-IPV 90460 Immunization administration through 18 years of age, counseling by physician; first or only component of vaccine……. diphtheria 90461 x 3 each additional component …. tetanus, pertussis, inactivated polio 90710 MMRV 90460 1st component……measles 90461 x 3 each additional component…mumps, rubella, varicella 90670 Pneumococcal conjugate 90460 Only component

23. You Would Report 99392 25 Preventive medicine, estab patient; 1 - 4 yrs of age 90696 DTaP-IPV 90710 MMRV 90670 Pneumococcal conjugate 90460 x 3 units 90461 x 6 units

24. Immunization Administration Medicare RVUs Medicare 2013 RBRVS Via injection: 90471 = .0.76 90472 = 0.37 Oral/intranasal: 90473 = 0.76 90474 = 0.37 Pediatric specific 90460 = 0.76 90461 = 0.37

26. The Evaluation & Management (E/M) Visit with IA • Separate from the product and administration • Must be significant, separately identifiable, & medically indicated • Must be documented • Vaccine counseling is notpart of a preventive medicine or problem-oriented visit

27. Medicare 2013 NCCI Edits • National Correct Coding Initiative (NCCI) • Pairs CPT codes 90471 and 90473 and 90460 and 90471 and 90473 • Pairs codes 90460, 90461, 90471-90474 with many E/M services • Modifier 25 must be appended to E/ M service to signify that it is significant and separately identifiable

28. Medicare NCCI Edits

29. Putting the Rules into Practice Patient is seen for her preventive medicine visit. Two combination vaccines were administered. Physician documents that he/she personally counseled the family/patient on one combination vaccine. What would you report?

30. You Would Report… First combination vaccine product code 90460 90461 with # units Second combination vaccine product code 90472 each additional vaccine

31. Putting the Rules into Practice 12 year old new patient is seen with complaints of headache during the last week. The meningococcal and Tdap (tetanus, diphtheria, and acellular pertussis) vaccines are administered. She is to receive the intranasal influenza vaccine but mother decides to wait until next week for administration. Immunization counseling is performed and documented on all vaccines by the physician and 2 vaccines are administered. How do you report these services?

32. You Would Report.. 9920x 25 Office/outpatient E/M, new patient 90734 Meningococcal vaccine 90715 Tdap 90460x2 Immunization administration, first component 90461x2 Each additional component How do you report the influenza vaccine and administration?

33. 12 Year Old – Deferred Immunization • You would report • 90660 Influenza virus, intranasal • 90473 Immunization administration, intranasal/oral; first vaccine • Codes 90460 and 90461 are only reported on the day that the IA counseling is performed and documented and the vaccine is administered

34. ICD-9-CM Rules • Preventive medicine - report PM code, vaccine and administration codes with V20.2 (well infant and child check, 29 days and older), V20.31 (newborn under 8 days) or V20.32 (newborn 8 to 28 days old) as primary • Specific need for prophylactic vaccination and inoculation code (V03-V06) may be reported as secondary if required by payer • Georgia Medicaid allows the diagnosis pointer for vaccine administration codes to be V20.2 when vaccine is provided during a health check visit for children 18 and under. 99393 (PM, estab, 5 through 11years) V20.2 90715 (Tdap) V20.2, V06.1 90460 and 90461 x2 (Admin, first and each additional component) or 90471 (Admin, first by injection) V20.2, V06.1

35. ICD-9-CM Rules • Problem-oriented visit - report vaccine and administration with specific need for prophylactic vaccination and inoculation code (V03-V06) 99201 – 99215 appropriate ICD-9-CM 90715 V06.1 90460 or 90471 V06.1 • Immunizations only (no E/M service) - report specific vaccine code (V03-V06) 90715 V06.1 90460 or 90471 V06.1 Payer guidelines may differ! Know them!

36. Other Important ICD-9-CM Codes • Vaccination not carried out codes used to explain why vaccine was not given (parent refusal, patient acutely ill) • Helps payers understand why vaccines are given at times other than at preventive medicine visit • May wish to use internally to track patients who refuse vaccine

37. Vaccination Not Carried Out • V64.01…. acute illness • V64.02…. chronic illness or condition • V64.05…. caregiver refusal • V64.06…. patient refusal • V64.07…. religious reasons • V64.08…. patient had disease being vaccinated against • V64.09…. for other reason

38. Under-Immunized ? • V15.83 Personal history of under-immunization status • Report with E/M service • Helps payer understand why vaccines are administered outside of preventive medicine visit

39. Health Check (Medicaid) • Always refer to the Health Check Manual regarding billing and reimbursement for children 0-19 and 19 and older. • The Health Check Manual is updated quarterly: January, April, July and October www.mmisgeorgia.gov

40. Practice Management

41. To Do List… • Learn payer guidelines and reporting requirements for immunization administration codes • Educate/communicate/negotiate with payers for appropriate coverage and payment • Verify coverage for each patient; educate patients • Notify/advise patients about reporting guidelines and deductible prior to appointment/service

42. To Do List…cont. • Set up EOB log and review processed claims • - Practice errors – correct, educate staff • - Payer errors – appeal and/or negotiate • Update all encounter forms- include CPT and ICD-9-CM code • Considerbuyer group for purchasing • Use coding and billing resources

43. Questions& Discussion

44. It’s a Team Effort! High immunization rates begin with a team designed plan! What can your team do to improve rates?

45. Other EPIC programs for your office • EPIC Immunization Programs • Childhood (Birth-18yrs.) • Adult (19yrs.-Senior) • Combo (Childhood/Adult) (Birth-Senior) • Women’s Health (OB-Gyn practices) • EPIC Breastfeeding Programs • Breastfeeding Fundamentals • Supporting Breastfeeding in the Hospital

46. To schedule a program:Contact EPIC Office 404.881.5054 – Immunization 404.881.5068 – Breastfeeding Or visit our website: www.GAepic.org