Immunization CodingImmunization Coding 20102010

The Basics and BeyondThe Basics and Beyond

Richard H. Tuck, MD, FAAPRichard H. Tuck, MD, FAAP

DisclosureDisclosureRichard H. Tuck, MD, FAAPRichard H. Tuck, MD, FAAP

I have financial relationships or interests with proprietary I have financial relationships or interests with proprietary entities producing health care goods entities producing health care goods or services related to the content of this CME activity. or services related to the content of this CME activity. I am Consulting Editor of Pediatric Coding Alert for Eli I am Consulting Editor of Pediatric Coding Alert for Eli Health Care. I Health Care. I serve on the speakers bureau for Sanofi Pasteur. serve on the speakers bureau for Sanofi Pasteur.

My content will not include discussion/My content will not include discussion/reference of any commercial products or services.reference of any commercial products or services.

I do not intend to discuss an unapproved/I do not intend to discuss an unapproved/investigative use of commercial products/devices.investigative use of commercial products/devices.

IMMUNIZATIONSIMMUNIZATIONSWhat’s New for 2010?What’s New for 2010?

PRODUCTS- FDA Approval PRODUCTS- FDA Approval ACIP-CDC-ACIP-CDC-AAP Adoption AAP Adoption VFC AdoptionVFC Adoption

CODES -CODES - New CPT/ICD CodesNew CPT/ICD Codes VALUE -VALUE - RBRVS – New RVU’s and CFRBRVS – New RVU’s and CF PAYER PAYMENT PAYER PAYMENT

Adoption of Vaccine Products, Timing, Payment Adoption of Vaccine Products, Timing, Payment PATIENTS-PATIENTS- Covered Covered

Benefits, Copays, DeductiblesBenefits, Copays, Deductibles CONTRACTS- Captitated Plans (Carve out CONTRACTS- Captitated Plans (Carve out

Immunizations!)Immunizations!)

Vaccines – Mission Critical !Vaccines – Mission Critical !

THE KEY preventive mission for THE KEY preventive mission for primary care physiciansprimary care physicians

– Evidence BasedEvidence Based

– Maintains the Public HealthMaintains the Public Health Explosion in vaccine productsExplosion in vaccine products

– Child born in 2010 will receive Child born in 2010 will receive over 50 vaccinations prior to adulthood over 50 vaccinations prior to adulthood

Vaccines – No Margin, No Mission !Vaccines – No Margin, No Mission !

The challenge: Maintaining a vaccine delivery systemThe challenge: Maintaining a vaccine delivery system

Requires both Requires both Clinical and Business SkillsClinical and Business Skills

A physician with 50 newborns per year could give A physician with 50 newborns per year could give 2000 vaccines (>$90,000 potential cost)2000 vaccines (>$90,000 potential cost)

Vaccines are now the second largest practice expense (non Vaccines are now the second largest practice expense (non universal states)universal states)

The Margin must support the Mission - It can The Margin must support the Mission - It can be financially profitable !be financially profitable !

Immunization BenefitsImmunization Benefits

Benefits for patientsBenefits for patients Benefits for practiceBenefits for practice

– Practice entry pointPractice entry point

»Reason for regular preventive medicine Reason for regular preventive medicine visitsvisits

»School entry requirementsSchool entry requirements

»College entry requirementsCollege entry requirements

Reimbursement KeysReimbursement Keys

Coding is EasyCoding is Easy Payment is complex, but payers are improvingPayment is complex, but payers are improving Contracting is key Contracting is key Group Purchasing is availableGroup Purchasing is available Understanding VFC requirements is importantUnderstanding VFC requirements is important Checking remittance advice (EOB) is criticalChecking remittance advice (EOB) is critical

ObjectivesObjectives Coding for Vaccines and ToxoidsCoding for Vaccines and Toxoids

To assure appropriate reimbursement for servicesTo assure appropriate reimbursement for services To meet reporting requirementsTo meet reporting requirements

– Immunization RegistriesImmunization Registries

– Vaccine Distribution ProgramsVaccine Distribution Programs To code for Evaluation and Management Services in To code for Evaluation and Management Services in

addition to immunization codes addition to immunization codes To understand CPT and ICD immunization codingTo understand CPT and ICD immunization coding

IMPORTANCE OF ACCURATE APPROPRIATE IMPORTANCE OF ACCURATE APPROPRIATE IMMUNIZATION CODING IMMUNIZATION CODING

INCREASED REIMBURSEMENTINCREASED REIMBURSEMENT

DECREASED LIABILITYDECREASED LIABILITY

IMPROVED INFORMATION FLOWIMPROVED INFORMATION FLOW

Vaccine Coding SpecificsVaccine Coding Specifics

Each vaccine has a specific Each vaccine has a specific CPTCPT code code

AMA identifies vaccines pending FDA approval AMA identifies vaccines pending FDA approval ~ code assigned~ code assigned

Each vaccine has an appropriate Each vaccine has an appropriate ICD-9ICD-9 diagnosis code diagnosis code

Each vaccine should be linked to an individual Each vaccine should be linked to an individual IAIA (immunization administration) code (immunization administration) code

Immunization Coding SummaryImmunization Coding Summary Bill and Document Bill and Document ALLALL::

– E/M VisitE/M Visit » Office Visit, Preventive MedicineOffice Visit, Preventive Medicine

– Immunization AdministrationImmunization Administration» 90471 – 9047490471 – 90474» 90465 - 90468 (2005 Peds specific)90465 - 90468 (2005 Peds specific)

– Vaccine/ToxoidVaccine/Toxoid» 90476 – 9074990476 – 90749

Link to ICD DiagnosesLink to ICD DiagnosesV20.2 Well ChildV20.2 Well ChildCSHCN DiagnosisCSHCN Diagnosis+ Specific Vaccine V Codes+ Specific Vaccine V Codes

Immunization Immunization Evaluation and Management CPT CodesEvaluation and Management CPT Codes

Office VisitOffice Visit

– NewNew (99201-99205)(99201-99205)

– EstablishedEstablished (99211-99215)(99211-99215) Preventive Medicine VisitPreventive Medicine Visit

– NewNew (99381-33385)(99381-33385)

– EstablishedEstablished (99391-99395)(99391-99395)

Preventive Medicine ServicesPreventive Medicine Services

99381 - 9939599381 - 99395 E/M services performed in the absence of a E/M services performed in the absence of a

significant problem/abnormalitysignificant problem/abnormality Do not includeDo not include office procedures, ancillary office procedures, ancillary

services, and services, and immunizationsimmunizations

25 Modifier25 Modifier

-25 Modifier -25 Modifier Distinct and separate E/M service provided at the Distinct and separate E/M service provided at the time of another E/M service or proceduretime of another E/M service or procedure

Not required by CPT for immunizations, Not required by CPT for immunizations, but may be required by specific payers for paymentbut may be required by specific payers for payment

99211 Nurse Immunizations99211 Nurse Immunizations

Bill 99211 in addition to immunization Bill 99211 in addition to immunization administration codes (90471 – 90474) if :administration codes (90471 – 90474) if :– Nurse provides health evaluation prior to the Nurse provides health evaluation prior to the

immunization (Medically Necessary E/M service)immunization (Medically Necessary E/M service)– Include vital signs (temperature, weight)Include vital signs (temperature, weight)– Document !Document !– Triggers a copayTriggers a copay

If immunization only, with no E/M services, bill If immunization only, with no E/M services, bill administration and product codes onlyadministration and product codes only

CPT Codes for Vaccine AdministrationCPT Codes for Vaccine Administration Reimburse for all expenses related to vaccine delivery other than product Reimburse for all expenses related to vaccine delivery other than product

purchasepurchase For VFC vaccine, there is a maximum administration fee (varies by state) – For VFC vaccine, there is a maximum administration fee (varies by state) –

OHIO $14.67OHIO $14.67 Choice of specific CPT code depends on:Choice of specific CPT code depends on:

– Whether first or subsequent vaccine that dayWhether first or subsequent vaccine that day– Whether injected or given orally/intranasallyWhether injected or given orally/intranasally– Whether patient is <8 yrs of age AND physician provides face-to-face counselingWhether patient is <8 yrs of age AND physician provides face-to-face counseling

Report an administration code for each vaccine givenReport an administration code for each vaccine given

*See AAP document “The Business Case for Pricing Vaccines and Immunization *See AAP document “The Business Case for Pricing Vaccines and Immunization Administration” www.cispimmunize.orgAdministration” www.cispimmunize.org

Billing for Vaccine AdministrationBilling for Vaccine Administration

Reimbursement for administration should coverReimbursement for administration should cover– Needle and syringeNeedle and syringe– Nurse work in administration Nurse work in administration – Gloves. Exam table paper, Band-aid, GauzeGloves. Exam table paper, Band-aid, Gauze– Required reportingRequired reporting– Immunization registry inputImmunization registry input

Does not include physician counselingDoes not include physician counseling Does not include other E/M servicesDoes not include other E/M services

EXISTING CPT CODES EXISTING CPT CODES 20042004Vaccine AdministrationVaccine Administration

9047190471 Immunization administration (includes percutaneous, intradermal, Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscularsubcutaneous, or intramuscular injections injections); ); one vaccineone vaccine (single or combination (single or combination vaccine/toxoid)vaccine/toxoid)

9047290472 each additional vaccineeach additional vaccine (single or combination vaccine/toxoid) (List (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)separately in addition to code for primary procedure)

9047390473 Immunization administration by Immunization administration by intranasal or oral routeintranasal or oral route; ; one vaccineone vaccine (single or combination vaccine/toxoid)(single or combination vaccine/toxoid)

9047490474 each additional vaccineeach additional vaccine (single or combination vaccine/toxoid) (List (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)separately in addition to code for primary procedure)

Vaccine Administration 2005Vaccine Administration 2005

Relative Value in RBRVS includes Relative Value in RBRVS includes Physician Work component Physician Work component

Requires Physician counseling Requires Physician counseling (and documentation)(and documentation)

Patient much be < 8 years oldPatient much be < 8 years old

2005 2005 ““NEWNEW”” CPT CODES CPT CODESVaccine AdministrationVaccine Administration

9046590465 Immunization administration Immunization administration under 8 years of ageunder 8 years of age (includes (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) percutaneous, intradermal, subcutaneous, or intramuscular injections) when the when the physician counselsphysician counsels the patient/family; first injection (single or combination the patient/family; first injection (single or combination vaccine/toxoid), per dayvaccine/toxoid), per day

9046690466each additional injection (single or combination vaccine/toxoid), per day each additional injection (single or combination vaccine/toxoid), per day 9046790467 Immunization administration Immunization administration under age 8 yearsunder age 8 years (includes (includes

intranasal or oral routes of administration) intranasal or oral routes of administration) when the physician counselswhen the physician counsels the the patient/family; first administration (single or combination vaccine/toxoid), per patient/family; first administration (single or combination vaccine/toxoid), per dayday

9046890468each additional administration (single or combination vaccine/toxoid), each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)per day (List separately in addition to code for primary procedure)

InjectableInjectableVaccineVaccine

Oral/IntranasalOral/IntranasalVaccineVaccine

Patient Patient <8 yrs of age<8 yrs of ageANDAND physician physician face-to-face counselingface-to-face counseling

90465904659046690466

90467904679046890468

All other situationsAll other situations90471904719047290472

90473904739047490474

CPT Codes for Vaccine AdministrationCPT Codes for Vaccine Administration

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

Vaccine AdministrationVaccine AdministrationRVUs for 2009RVUs for 2009

Values - Existing codesValues - Existing codes RVU 2009 medicareRVU 2009 medicare RVU 2009 medicareRVU 2009 medicare

– 9047190471 –– 0.58/ 0.58/ $20.92$20.92 9047290472 –– 0.29/ 0.29/ $10.46$10.46 – 90473 90473 –– 0.38/ $13.710.38/ $13.71 90474 90474 –– 0.25/ $ 9.020.25/ $ 9.02

Values - New codesValues - New codes– 9046590465 –– 0.58/ 0.58/ $20.92$20.92 9046690466 –– 0.29/ 0.29/ $10.46$10.46- 9046790467--0.38/ $13.710.38/ $13.71 90468 90468 –– 0.28/ $10.100.28/ $10.10

Ohio VFC payment $5.00 Ohio VFC payment $5.00 → $10.00→ $10.00

New Code Administration GuidelinesNew Code Administration Guidelines

One initial administration code per visitOne initial administration code per visit Example: 2 month infant receiving immunizationsExample: 2 month infant receiving immunizations

– 90465 - initial injection90465 - initial injection (Dtap/IPV/HIB) (Dtap/IPV/HIB)

– 90466 X 2 – subsequent 2 injections (Prevnar, Hep B)90466 X 2 – subsequent 2 injections (Prevnar, Hep B)

– 90468 – subsequent oral vaccine (Rotavirus)90468 – subsequent oral vaccine (Rotavirus) Always make first administration the injection Always make first administration the injection

(higher relative value than oral vaccine) (higher relative value than oral vaccine)

New Code Administration GuidelinesNew Code Administration Guidelines

Physician counseling (face-to-face) apply only Physician counseling (face-to-face) apply only for new codes (90465-90468)for new codes (90465-90468)

? Immunization administration code to use with ? Immunization administration code to use with 99211 nurse only immunization visit (<8 years)99211 nurse only immunization visit (<8 years)– 90471 - 9047490471 - 90474

? Need for physician face-to-face counseling ? Need for physician face-to-face counseling at each visit for boostersat each visit for boosters

New Code Administration GuidelinesNew Code Administration Guidelines

Can advanced practice nurses (APNs) report Can advanced practice nurses (APNs) report 90465-90468 if providing counseling?90465-90468 if providing counseling?– Yes, if within state-licensed scope of practiceYes, if within state-licensed scope of practice

Can a nurse report 90465-90468 as “incident to” Can a nurse report 90465-90468 as “incident to” the physician?the physician?– No, require physicians do the counselingNo, require physicians do the counseling

Immunization AdministrationImmunization Administration

If a If a significant separately identifiablesignificant separately identifiable E/M service E/M service (eg. Office, preventive medicine, other outpatient) (eg. Office, preventive medicine, other outpatient) is performed, the appropriate E/M service code is performed, the appropriate E/M service code should be reported should be reported in addition toin addition to the the vaccine/toxoid administration codes.vaccine/toxoid administration codes.

-25 modifier with E/M code not required by CPT, -25 modifier with E/M code not required by CPT, However, may be required by some payersHowever, may be required by some payers

Preventive Medicine Ancillary ServicesPreventive Medicine Ancillary ServicesScreening RVU/ 2009 Medicare

Hearing testing - Select picture 92583 .91/ $31.30Hearing testing – Puretone 92551 .29/ $10.46Hearing testing – Puretone(threshold) 92552 .59/ $21.28Vision screening 99173 .07/ $2.52Developmental Screening 96110 .36/ $12.98

LabHemoglobin 85018 .10/ $3.45Urine (dip only) 81002 .08/ $2.78Routine Venipuncture 36415 .26/ $9.17Finger/Heel Stick 36416 .15/ $5.25

ImmunizationsImmunization administration 90471/90465 .58/ $20.92

90472/90466 .29/ $10.46Vaccine/Toxoid product 90476-90479

OtherInjection/other 96372 .58/ $20.17

New Vaccine Counseling Payment IssuesNew Vaccine Counseling Payment Issues

Payment for extensive additional counseling time Payment for extensive additional counseling time related to increased parent concernsrelated to increased parent concerns

Payment for time spent counseling when vaccines Payment for time spent counseling when vaccines refusedrefused

Payment for additional counseling when parents Payment for additional counseling when parents insist vaccines spaced out beyond recommended insist vaccines spaced out beyond recommended scheduleschedule

Time Based Time Based ExtensiveExtensive Counseling Counseling

Coding Option 99401-99404 with Preventive Coding Option 99401-99404 with Preventive Medicine Codes Counseling in Medicine Codes Counseling in 15 minute increments15 minute increments

Code based on Time for Office Visit Codes Over Code based on Time for Office Visit Codes Over 50% face to face visit time spent counseling50% face to face visit time spent counseling

– 99212 – 10 minutes99212 – 10 minutes

– 99213 - 15 minutes99213 - 15 minutes

– 99214 – 25 minutes99214 – 25 minutes

-25 modifier on E/M office visit code-25 modifier on E/M office visit code

? Alternate Vaccine Schedules ?? Alternate Vaccine Schedules ?

Additional visits can justify a Additional visits can justify a 99211-2599211-25 charge if charge if nurse provides distinct E/M work discussing nurse provides distinct E/M work discussing parent concerns parent concerns If physician face to face discussion: If physician face to face discussion: ≥ 99212-25≥ 99212-25 based on timebased on time

Additional initial vaccine administration charges Additional initial vaccine administration charges will result in overall increased charges to the will result in overall increased charges to the patient for extended schedules patient for extended schedules However, there is increased practice expenseHowever, there is increased practice expense

Multiple Component Vaccine IssuesMultiple Component Vaccine Issues

ProsPros– Fewer injections for childrenFewer injections for children– Less nurse work/practice expenseLess nurse work/practice expense– Documented improved compliance with AAP Documented improved compliance with AAP

recommended vaccine schedules (5%)recommended vaccine schedules (5%) ConsCons

– Parent concerns with multiple antigen vaccinesParent concerns with multiple antigen vaccines– Loss in Immunization Administration paymentsLoss in Immunization Administration payments

Multiple Antigen Vaccine SolutionsMultiple Antigen Vaccine Solutions New Immunization Administration CodesNew Immunization Administration Codes

– Current AAP COCN initiativeCurrent AAP COCN initiative– Based on number of antigens in vaccinesBased on number of antigens in vaccines

Increased payer payment for multiple antigen vaccinesIncreased payer payment for multiple antigen vaccines– Potential win/winPotential win/win– Humana – Additional $14 for multiple antigen vaccinesHumana – Additional $14 for multiple antigen vaccines– United – Additional product payment for Pentacel (List price plus United – Additional product payment for Pentacel (List price plus

20% + $10)20% + $10)– Wellpoint- Additional product payment 7/1/10Wellpoint- Additional product payment 7/1/10– Positive medicaid (VFC) precedents in other statesPositive medicaid (VFC) precedents in other states

20112011 Immunization Administration CodesImmunization Administration Codes

2011 New Immunization Administration Codes2011 New Immunization Administration Codes Old IA code sets will be deleted Old IA code sets will be deleted

(90471-90474; 90465-90468)(90471-90474; 90465-90468) New IA codes based on number of components New IA codes based on number of components

in a vaccinein a vaccine– 1 1 ComponentComponent (IPV, Influenza)(IPV, Influenza)– 2-4 2-4 ComponentsComponents (MMRV, Tdap)(MMRV, Tdap)– ≥≥55 Components Components (Dtap-IPV-HIB)(Dtap-IPV-HIB)

Vaccine/Toxoid CPT CodesVaccine/Toxoid CPT Codes

CPT codes developed to meet reporting requirementsCPT codes developed to meet reporting requirements 90476 – 9074990476 – 90749 Identify the specific vaccine product onlyIdentify the specific vaccine product only

– CPT differentiates vaccines with differentCPT differentiates vaccines with different» Conjugate materialConjugate material» Mode of administrationMode of administration» Age indication (usually dosing difference)Age indication (usually dosing difference)» PreservativePreservative

– Use in addition to administration codesUse in addition to administration codes

CPT 2010CPT 2010Vaccines/ToxoidsVaccines/Toxoids

Term “preservative free” includes products containing Term “preservative free” includes products containing either very little or no preservativeseither very little or no preservatives

90669 revised90669 revised– Pneumococcal vaccine – 7 valentPneumococcal vaccine – 7 valent

9067090670– Pneumococcal vaccine – 13 valentPneumococcal vaccine – 13 valent

9037890378– Respiratory Syncytial Virus – monoclonal antibody, Respiratory Syncytial Virus – monoclonal antibody,

recombinant, 50 mg eachrecombinant, 50 mg each++96372 96372 Injection codeInjection code

H1N1 Influenza CodingH1N1 Influenza Coding CPTCPT

– 9047090470 - H1N1 IA, any route, including counseling $24 - H1N1 IA, any route, including counseling $24– 90465-90468, 90471-90472 – if directed by plan90465-90468, 90471-90472 – if directed by plan– G9141G9141- H1N1 IA, any route, including counseling Ohio - H1N1 IA, any route, including counseling Ohio

Medicare $19.95Medicare $19.95 ICD ICD

– 9066390663 – Influenza vaccine, pandemic formulation – Influenza vaccine, pandemic formulation– G9142G9142 –Influenza A vaccine (H1N1), any route –Influenza A vaccine (H1N1), any route

administrationadministration– $0 vs. $0.01 charge$0 vs. $0.01 charge

H1N1 Influenza Testing CodingH1N1 Influenza Testing Coding

Rapid Influenza testingRapid Influenza testing– If testing for two distinct virus strains (A & B) If testing for two distinct virus strains (A & B)

Report test for rapid influenza test twice Report test for rapid influenza test twice 87804 87804 87804-59 (distinct procedure modifier)87804-59 (distinct procedure modifier)

Vaccine ICD CodingVaccine ICD Coding

Link CPT to ICD codingLink CPT to ICD coding E/M to ICD codeE/M to ICD code

– Office Visit to appropriate ICD diagnosisOffice Visit to appropriate ICD diagnosis

– Preventive Medicine to V code Preventive Medicine to V code V 20.2 (routine infant or child V 20.2 (routine infant or child health check)health check)

Vaccine specific CPT code to Vaccine specific CPT code to Vaccine specific ICD V codeVaccine specific ICD V code

V - CodesV - Codes

V 04.0 to V 06.9 V 04.0 to V 06.9 VaccinesVaccines– V06.1V06.1 DtapDtap– V04.0V04.0 IPVIPV– V03.81V03.81 HIBHIB– V06.4V06.4 MMRMMR– V05.4V05.4 VarivaxVarivax

ICD Changes for ICD Changes for 20062006 V64.00 Vaccination not carried outV64.00 Vaccination not carried out

– V64.01V64.01 Acute illnessAcute illness– V64.02V64.02 Chronic illnessChronic illness– V64.03V64.03 Immune compromised stateImmune compromised state– V64.04V64.04 Allergy to vaccineAllergy to vaccine– V64.05V64.05 Caregiver refusalCaregiver refusal– V64.06V64.06 Patient refusalPatient refusal– V64.07V64.07 Religious reasonsReligious reasons– V64.08V64.08 Had disease being vaccinated againstHad disease being vaccinated against

E/M Visit CodesE/M Visit CodesHealth Supervision VisitsHealth Supervision Visits

CPTCPT– Preventive E/M Codes (99381-99397)Preventive E/M Codes (99381-99397)– Vaccine Product CodesVaccine Product Codes– Vaccine Administration CodesVaccine Administration Codes

ICDICD– Health supervision of infant/child (v20.2)Health supervision of infant/child (v20.2)

» USE ONLY IN CONJUNCTION WITH A PREVENTIVE CPT CodeUSE ONLY IN CONJUNCTION WITH A PREVENTIVE CPT Code

– Vaccine specific ICD CodesVaccine specific ICD Codes

E/M Visit Codes E/M Visit Codes Sick VisitsSick Visits CPTCPT

– Office/outpatient E/M Codes (99201-99215)Office/outpatient E/M Codes (99201-99215)» Payers may require modifier –25 be appended to E/M visit codePayers may require modifier –25 be appended to E/M visit code

– Vaccine Product CodesVaccine Product Codes– Vaccine Administration CodesVaccine Administration Codes

ICDICD– Link E/M Code to the ICD reason for visit –Link E/M Code to the ICD reason for visit –

(eg, otitis media 382.0) (eg, otitis media 382.0)– Link each Vaccine Product/Administration CPT code to a separate ICD code:Link each Vaccine Product/Administration CPT code to a separate ICD code:

» Vaccine specific V codeVaccine specific V code» ““need for prophylactic vaccination…” (eg, DTP v06.1)need for prophylactic vaccination…” (eg, DTP v06.1)» DO NOT USE v20.2 (health supervision)DO NOT USE v20.2 (health supervision)

E/M Visit CodesE/M Visit CodesImmunization-Only VisitImmunization-Only Visit

CPTCPT– No E/M codeNo E/M code

» 99211 only if medically necessary separate E/M service99211 only if medically necessary separate E/M service

– Vaccine Product CodesVaccine Product Codes– Vaccine Administration CodesVaccine Administration Codes

ICDICD– Link each Vaccine Product /Administration CPT code to a Link each Vaccine Product /Administration CPT code to a

separate ICD code:separate ICD code:» Vaccine specific V codeVaccine specific V code

» ““need for prophylactic vaccination…” (eg, DTP v06.1)need for prophylactic vaccination…” (eg, DTP v06.1)

» DO NOT USE v20.2 (health supervision)DO NOT USE v20.2 (health supervision)

Best Vaccine Business PracticesBest Vaccine Business Practices

Code CorrectlyCode Correctly Contract with Knowledge Contract with Knowledge Purchase at the Best PricePurchase at the Best Price

Business Case For Providing Business Case For Providing ImmunizationsImmunizations

Cost of providing vaccinesCost of providing vaccines– $ tied up in inventory$ tied up in inventory– No profit over product costNo profit over product cost– Potential loss with poor paymentsPotential loss with poor payments

Determining practice expenses related to Determining practice expenses related to providing vaccinesproviding vaccines

VFC/ Medicaid FFS/Managed Care confusionVFC/ Medicaid FFS/Managed Care confusion– The mission vs business senseThe mission vs business sense

Business Case - VaccinesBusiness Case - Vaccines Reimbursement should coverReimbursement should cover

– Vaccine ProductVaccine Product»Price of the productPrice of the product»Shipping and handlingShipping and handling»Excise taxExcise tax»StorageStorage» Inventory ManagementInventory Management»LossLoss» InsuranceInsurance»Tracking claimsTracking claims

Business Case - VaccinesBusiness Case - Vaccines

American Academy of Pediatrics estimates:American Academy of Pediatrics estimates:– Losses/waste ~ 5%Losses/waste ~ 5%

»Patients change their mindPatients change their mind»Excess stock (influenza)Excess stock (influenza)»Office lossesOffice losses»Expired vaccines Expired vaccines

– Payment should be 17–28% over cost In Payment should be 17–28% over cost In addition to administration paymentaddition to administration payment

CaseCase

A 2-year old child with private insurance is seen in A 2-year old child with private insurance is seen in September for a contact dermatitis. He has not September for a contact dermatitis. He has not been seen since 9 months of age and you been seen since 9 months of age and you administer the following vaccines: MMR#1, administer the following vaccines: MMR#1, Var#1, Hib#4, PCV#4, HepA#1, DTaP#4 and Var#1, Hib#4, PCV#4, HepA#1, DTaP#4 and LAIV. A future well visit is scheduled for one LAIV. A future well visit is scheduled for one month later before the patient leaves the office.month later before the patient leaves the office.

How would you code this encounter?How would you code this encounter?

Contact Contact derm–derm–

MMR#1MMR#1

Var#1Var#1

Hib#4Hib#4

PCV#4PCV#4

HepA#1HepA#1

DTaP#4DTaP#4

LAIVLAIV

CPTCPT ## descriptiondescription ICDICD descripdescrip

99213-2599213-25 11 E/M visitE/M visit 692.9692.9 DermatitisDermatitis

9070790707 11 MMRMMR v06.4v06.4 need for…need for…

9071690716 11 VaricellaVaricella v05.4v05.4 need for…need for…

9064890648 11 HibHib v03.81v03.81 need for…need for…

9066990669 11 PCVPCV v03.82v03.82 need for…need for…

9063390633 11 HepAHepA v05.3v05.3 need for…need for…

9070090700 11 DTaPDTaP v06.1v06.1 need for…need for…

9066090660 11 LAIVLAIV v04.81v04.81 need for…need for…

9047190471 11 11stst vacc, inj vacc, inj v06.1v06.1 need for…need for…

9047290472 55 Each add’l injEach add’l inj v…v… need for…need for…

9047490474 11 Each add’l oral/nasalEach add’l oral/nasal v04.89v04.89 need for…need for…

DOCUMENT !DOCUMENT !

DOCUMENT !DOCUMENT !

DOCUMENT !DOCUMENT !

Vaccine ResourcesVaccine Resources

CDC – CDC – www.cdc.gov/nip AAP – AAP – www.aap.org MOC MOC Immunization Action Coalition – Immunization Action Coalition –

www.immunize.org SanofiPasteur – “Library” – SanofiPasteur – “Library” –

www.vaccineshoppe.comwww.vaccineshoppe.com

Reference DocumentsReference Documents

AAP Vaccine Coding Table 2010AAP Vaccine Coding Table 2010 AAP Business Case for Vaccine ProductsAAP Business Case for Vaccine Products AAP Red Book Vaccine Pipeline 2007AAP Red Book Vaccine Pipeline 2007 CDC-ACIP Vaccine Recommendations 2010 CDC-ACIP Vaccine Recommendations 2010

www.cdc.gov/nip/acip Vaccine Information Sheets (VIS) Vaccine Information Sheets (VIS)

www.immunize.org SanofiPasteur website www.vaccineshoppe.comSanofiPasteur website www.vaccineshoppe.com

AAP Your CODING CONNECTION AAP Your CODING CONNECTION Coding & Reimbursement ResourcesCoding & Reimbursement Resources

National AAP Coding Hotline: National AAP Coding Hotline: aapcodinghotline@aap.org ; free service ; free service to members and their office staffto members and their office staff

Coding publications: Coding for Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Pediatrics, Pediatric Coding Companion, Quick Reference Guides, ICD-9-CM Quick Reference Guides, ICD-9-CM Flipchart, RBRVS Brochure, Flipchart, RBRVS Brochure, AAP NewsAAP News Coding CornerCoding Corner