# New CCI edit for vaccine admins billed same DOS as E/M?



## volleyb13 (Jan 18, 2013)

Hello all,

Was hoping someone could help me find some info on a new CCI edit we have come across for 2013.

When we bill for a 99201-99215 or 99381-99397 with a vaccine admin code (ex 90471), we now receive an error stating the E/M requires a 25 modifier. 

We never received this prior to 2013, nothing new shows on the CCI edits manual for this, and cannot find any info on the internet about the change.

The CCI edit error states reason is CPT/HCPCS Coding Manual Instruction/Guideline.

Was wondering if anyone else has seen this & has found any info on the change?

Any info would be great!!! Thanks in advance!


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## Tanna717 (Mar 7, 2013)

*Any news?*

I myself am looking for the exact same thing!! Have you found this yet?

Tara


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## Pam Brooks (Mar 8, 2013)

I have it.  Green text under the Immunization Administration for Vaccines/Toxoids (AMA's CPT 2013-Professional  edition, page 478-479) indicates if a significant separately identifiable E&M is performed, the appropriate E&M service should b reported in addition. 

If you consider the language "significant and separately identifiable", this is coding guidance that means appending a -25 modifier.  CPT won't tell you what modifier to append (usually).  It assumes the coder understands the use of modifiers and when they are to be appended.


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## Tanna717 (Mar 8, 2013)

Thank you Pam!


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## Lynda Wetter (Mar 14, 2013)

Check this out too...

http://www.aap.org/en-us/profession...port/coding-resources/Pages/Announcement.aspx

Article Body
On January 1, 2013, new Procedure-to-Procedure (PTP) edits were implemented in the Medicare and Medicaid NCCI that paired the immunization administration codes (CPT codes 90460 – 90474) as column one codes with preventive medicine Evaluation & Management (E&M) service codes (CPT codes 99381 – 99397) as column two codes. All of the edits have a Correct Coding Modifier Indicator (CCMI) of “1”, which permits the edit to be bypassed, if a PTP-associated modifier is correctly appended to one of the CPT codes.

The edits are based on the instruction in the section on “Immunization Administration for Vaccines/Toxoids” in the 2013 CPT Manual, which states:

If a significant separately identifiable Evaluation and Management service (e.g., new or established patient office or other outpatient services [99201 – 99215], office or other outpatient consultations [99241 – 99245], emergency department services [99281 – 99285], preventive medicine services [99381 – 99429]) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes.

It has been long-standing CMS and NCCI policy that, when this type of instruction, which allows separate reporting of a significant, separately identifiable E&M service, is present, edits are established with a CCMI of “1”. This permits payment of both codes, if a significant, separately identifiable E&M service is provided on the same day and a PTP-associated modifier (i.e., modifier 25) is appended to the E&M code. The edit prevents inappropriate payment of a preventive medicine E&M service, if the beneficiary just returns to the physician's office for the immunization on a day other than the day of a comprehensive preventive medicine E&M service. Many similar edits have been present in the NCCI program for a number of years.

As a result of comments received from the American Academy of Pediatrics and some state Medicaid agencies, CMS has decided to permit state Medicaid agencies to deactivate these edits in their Medicaid Management Information Systems through the end of 2013, if they choose to do so, retroactive to January 1, 2013. States do not have to file a formal deactivation request through their CMS Regional Office to do so. Table 1 identifies the edits in question. 

State Medicaid agencies that choose to retain the edits should educate providers to report E&M codes with immunization administration codes, if the E&M service is significant and separately identifiable. States should notify providers that the proper use of modifier 25 with an E&M service code will bypass the PTP edits.


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## mjarrell (Apr 26, 2013)

It has been long-standing CMS and NCCI policy that, when this type of instruction, which allows separate reporting of a significant, separately identifiable E&M service, is present, edits are established with a CCMI of “1”. This permits payment of both codes, if a significant, separately identifiable E&M service is provided on the same day and a PTP-associated modifier (i.e., modifier 25) is appended to the E&M code. [B]The edit prevents inappropriate payment of a preventive medicine E&M service, if the beneficiary just returns to the physician's office for the immunization on a day other than the day of a comprehensive preventive medicine E&M service.[/B] Many similar edits have been present in the NCCI program for a number of years.

I'm sorry, this statement doesn't make sense to me.  

If the patient returns to the office on a different day for the immunization, only the immunization charge should be submitted  - and does not receive an E&M, there should be no E&M code billed, therefore, no need for the modifier -25.  So how does this edit prevent that circumstance? Are NCCI edits not based on DOS?

I'm concerned about the fact that the immunization codes have been made the Column 1 Codes in NCCI - that implies  to me that a certain amount of E&M is considered inherent to those services.  How do you recommend determining what actually is Significant & Separate?  If a modifier is necessary to establish that it is significant and separate, I worry that it's use should be the exception rather than the rule and that applying the modifier -25 to the PM code every time a vaccination is administered will be a "red flag" during claims data mining with payors.  Thanks for your insight.


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## Lynda Wetter (Apr 26, 2013)

If a patient comes in for a HM exam...993XXX and has their immunizations they are not there JUST for the immunizations. They are having their annual physical. NCCI bundles the use of the immunization and the E/M visit. So Mod 25 is apropriate in that case. If a pt comes in with a laceration and they decide to get their Teanus shot you can apply the 25 to the OV 992XX code apropriately. 
But as you said if a patient comes in just for their immunization/vaccination/injection than no ov would be apropriate to bill.
If indeed there was a "seperate evaluation" 25 is apropriate. If you read the article posted from the Americam Academy of Pediatrics you will see this is under review and will mostly be corrected when the new edits are released. 
You can also see on page 479 in CPT where it does state that 25 is ok when applied properly.


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