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

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

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

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

6. 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 !

7. Immunization Benefits Benefits for patients Benefits for patients Benefits for practice Benefits for practice –Practice entry point »Reason for regular preventive medicine visits »School entry requirements »College entry requirements

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

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

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

12. Vaccine Coding Specifics Each vaccine has a specific CPT code 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 has an appropriate ICD-9 diagnosis code Each vaccine should be linked to an individual IA (immunization administration) code Each vaccine should be linked to an individual IA (immunization administration) code

13. Immunization Coding Summary Bill and Document ALL: 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 Link to ICD Diagnoses V20.2 Well Child CSHCN Diagnosis + Specific Vaccine V Codes

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

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

17. 25 Modifier -25 Modifier Distinct and separate E/M service provided at the time of another E/M service or procedure -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 Not required by CPT for immunizations, but may be required by specific payers for payment

18. 99211 Nurse Immunizations Bill 99211 in addition to immunization administration codes (90471 – 90474) if : 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 If immunization only, with no E/M services, bill administration and product codes only

19. CPT Codes for Vaccine Administration Reimburse for all expenses related to vaccine delivery other than product purchase 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 For VFC vaccine, there is a maximum administration fee (varies by state) – OHIO $14.67 Choice of specific CPT code depends on: 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 Report an administration code for each vaccine given *See AAP document “The Business Case for Pricing Vaccines and Immunization Administration” www.cispimmunize.org

20. Billing for Vaccine Administration Reimbursement for administration should cover 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 physician counseling Does not include other E/M services Does not include other E/M services

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

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

23. 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 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 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 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) 90468 each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)

24. Injectable Vaccine Oral/Intranasal Vaccine Patient <8 yrs of age AND physician face-to-face counseling 90465 90466 90467 90468 All other situations 90471 90472 90473 90474 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.

25. Vaccine Administration RVUs for 2009 Vaccine Administration RVUs for 2009 Values - Existing codes Values - Existing codes RVU 2009 medicareRVU 2009 medicare RVU 2009 medicareRVU 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 Values - New codes –90465 – 0.58/ $20.92 90466 – 0.29/ $10.46 -90467-0.38/ $13.7190468 – 0.28/ $10.10 Ohio VFC payment $5.00 → $10.00

26. New Code Administration Guidelines One initial administration code per visit One initial administration code per visit Example: 2 month infant receiving immunizations 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) Always make first administration the injection (higher relative value than oral vaccine)

27. New Code Administration Guidelines Physician counseling (face-to-face) apply only for new codes (90465-90468) 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) ? 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 ? Need for physician face-to-face counseling at each visit for boosters

28. New Code Administration Guidelines Can advanced practice nurses (APNs) report 90465-90468 if providing counseling? 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? Can a nurse report 90465-90468 as “incident to” the physician? –No, require physicians do the counseling

29. 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. 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 -25 modifier with E/M code not required by CPT, However, may be required by some payers

30. 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

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

32. Time Based Extensive Counseling Coding Option 99401-99404 with Preventive Medicine Codes Counseling in 15 minute increments 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 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

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

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

35. Multiple Antigen Vaccine Solutions New Immunization Administration Codes New Immunization Administration Codes –Current AAP COCN initiative –Based on number of antigens in vaccines Increased payer payment for multiple antigen 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

36. 2011 Immunization Administration Codes 2011 New Immunization Administration Codes 2011 New Immunization Administration Codes Old IA code sets will be deleted (90471-90474; 90465-90468) Old IA code sets will be deleted (90471-90474; 90465-90468) New IA codes based on number of components in a vaccine New IA codes based on number of components in a vaccine –1 Component(IPV, Influenza) –2-4 Components(MMRV, Tdap) –≥5Components (Dtap-IPV-HIB)

38. Vaccine/Toxoid CPT Codes CPT codes developed to meet reporting requirements CPT codes developed to meet reporting requirements 90476 – 90749 90476 – 90749 Identify the specific vaccine product only 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

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

40. H1N1 Influenza Coding CPT 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 ICD –90663 – Influenza vaccine, pandemic formulation –G9142 –Influenza A vaccine (H1N1), any route administration –$0 vs. $0.01 charge

41. H1N1 Influenza Testing Coding Rapid Influenza testing 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)

42. Vaccine ICD Coding Link CPT to ICD coding Link CPT to ICD coding E/M to ICD code 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 Vaccine specific CPT code to Vaccine specific ICD V code

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

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

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

46. E/M Visit Codes Sick Visits CPT 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 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)

47. E/M Visit Codes Immunization-Only Visit CPT CPT –No E/M code »99211 only if medically necessary separate E/M service –Vaccine Product Codes –Vaccine Administration Codes ICD 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)

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

49. Business Case For Providing Immunizations Cost of providing vaccines 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 Determining practice expenses related to providing vaccines VFC/ Medicaid FFS/Managed Care confusion VFC/ Medicaid FFS/Managed Care confusion –The mission vs business sense

51. Business Case - Vaccines Reimbursement should cover Reimbursement should cover –Vaccine Product »Price of the product »Shipping and handling »Excise tax »Storage »Inventory Management »Loss »Insurance »Tracking claims

52. Business Case - Vaccines American Academy of Pediatrics estimates: 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

53. 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?

54. Contact derm– MMR#1Var#1Hib#4PCV#4HepA#1DTaP#4LAIV CPT#descriptionICDdescrip 99213-251 E/M visit 692.9Dermatitis 907071MMRv06.4 need for… 907161Varicellav05.4 906481Hibv03.81 906691PCVv03.82 906331HepAv05.3 907001DTaPv06.1 906601LAIVv04.81 904711 1 st vacc, inj v06.1 need for… 904725 Each add’l inj v… need for… 904741 Each add’l oral/nasal v04.89 need for…

56. DOCUMENT ! DOCUMENT ! DOCUMENT !

57. Vaccine Resources CDC – www.cdc.gov/nip CDC – www.cdc.gov/nipwww.cdc.gov/nip AAP – www.aap.org MOC AAP – www.aap.org MOCwww.aap.org Immunization Action Coalition – www.immunize.org Immunization Action Coalition – www.immunize.org www.immunize.org SanofiPasteur – “Library” – www.vaccineshoppe.com SanofiPasteur – “Library” – www.vaccineshoppe.com

58. Reference Documents AAP Vaccine Coding Table 2010 AAP Vaccine Coding Table 2010 AAP Business Case for Vaccine Products AAP Business Case for Vaccine Products AAP Red Book Vaccine Pipeline 2007 AAP Red Book Vaccine Pipeline 2007 CDC-ACIP Vaccine Recommendations 2010 www.cdc.gov/nip/acip CDC-ACIP Vaccine Recommendations 2010 www.cdc.gov/nip/acip www.cdc.gov/nip/acip Vaccine Information Sheets (VIS) www.immunize.org Vaccine Information Sheets (VIS) www.immunize.org www.immunize.org SanofiPasteur website www.vaccineshoppe.com SanofiPasteur website www.vaccineshoppe.com

59. AAP Your CODING CONNECTION Coding & Reimbursement Resources National AAP Coding Hotline: aapcodinghotline@aap.org ; free service to members and their office staff National AAP Coding Hotline: aapcodinghotline@aap.org ; free service to members and their office staff aapcodinghotline@aap.org Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Quick Reference Guides, ICD-9-CM Flipchart, RBRVS Brochure, AAP News Coding Corner Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Quick Reference Guides, ICD-9-CM Flipchart, RBRVS Brochure, AAP News Coding Corner