Internal Medicine Coding Alert

Plus: Subsequent observation codes apply to longer hospital stays.

CPT 2011 is just around the corner, and brings some welcome additions to your observation care and vaccine administration coding choices.

Best news: The new vaccine administration codes are expected to help boost physicians' bottom lines.

Vaccine Codes Note Wider Age Range

Previous editions of CPT included vaccine administration codes (90465-90468) for children younger than 8 years of age when the internist counseled the patient/family. CPT 2011 introduces two administration codes that expand the concept to include adolescents and teens and eliminates the distinction based on route of administration:

• 90460 -- Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component
• 90461 -- ... each additional vaccine/toxoid component (List separately in addition to code for primary procedure).

You could find yourself frequently relying on 90460 and 90461 if your internist often provides counseling in conjunction with vaccinations for patients 18 or under.

"I think part of the supposed need for these codes was the increasing prevalence of multicomponent vaccines," says Kent J. Moore, manager of healthcare delivery and financing systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. "The physician needs to counsel regarding each component but the coding didn't distinguish that higher amount of counseling from counseling for a single component vaccine. The switch allows physicians to get credit for each component on which they counsel, not the number of shots given."

Components Drive Vaccine Descriptors

"New immunization administration codes in 2011 are based on the number of 'components' in the vaccine," explains Richard L. Tuck, MD, FAAP, a physician at PrimeCare of Southeastern Ohio in Zanesville.

Example: Imagine an internist counsels a young child's mother about the benefits and risks of an MMR vaccine, then administers the vaccine to the child. Assuming that is the only vaccine administered, in 2010 you would report administration code 90465 (Immunization administration younger than 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).

In 2011, you will code the same administration with 90460 and two units of 90461 because MMR has three components (i.e., measles, mumps, and rubella). The increase in multiple component vaccines in recent years meant that internists administered fewer injections for the same disease. Physicians lost significant income by not being able to report multiple administration codes, even though the counseling associated with a multi-component vaccine is multiple times greater than a single component vaccine. "The new codes should allow for improved payment for the work associated with administering a multiple antigen/multiple component vaccine," Tuck says.

Other multi-component vaccine codes to watch on your claims include 90696 (Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated [DTaP-IPV], when administered to children 4 through 6 years of age, for intramuscular use), 90698 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated [DTaP-Hib-IPV], for intramuscular use), 90710 (Measles, mumps, rubella, and varicella vaccine [MMRV], live, for subcutaneous use), 90723 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated [DtaP-HepBIPV], for intramuscular use), 90748 (HepatitisB and Hemophilus influenza b vaccine [HepB-Hib], for intramuscular use).

New choice: If your physician treats infants and toddlers, be aware of new vaccine product code 90644 (Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine, tetanus toxoid conjugate [Hib-MenCY-TT], 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use).

"Internists who see children will use this code," says Moore, "but pediatricians will use it more."

Add 4 Influenza Choices to Your Charge Sheet

The bulk of new vaccine product codes represent influenza shots. Descriptors specify several details that distinguish each product:

• 90664 - Influenza virus vaccine, pandemic formulation, live, for intranasal use
• 90666 - Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use
• 90667 - Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use
• 90668 - Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use.

H1N1 Changes Added to CPT, ICD-9

The AMA introduced a new code for H1N1 in 2010, but CPT books didn't include it. Now CPT 2011 includes 90470 (H1N1 immunization administration (intramuscular, intranasal), including counseling when performed).

Related change: ICD-9 2011 also incorporates new codes related to H1N1. New diagnoses 488.0x (Influenza due to identified avian influenza virus) and 488.1x (Influenza due to identified novel H1N1 influenza virus) allow you to capture pneumonia, other respiratory manifestations, and other manifestations occurring with avian influenza or H1N1.

Assign the correct 488.xx code based on the type of co-morbid manifestation the avian or H1N1 influenza involves. Include an additional code to identify the type of pneumonia (480.0-480.9, 481, 482.0-482.9, 483.0-483.8, or 485).

Check Your New Subsequent Care Choices

Historically, patients admitted to observation status in a hospital were either discharged or admitted as an inpatient within 24 hours. Consequently, observation care codes recognized initial observation care (99218-99220), observation discharge (99217), or both services when provided on the same date (99234-99236).

Changes: In recent years and for multiple reasons, physicians might keep patients may in observation status for multiple days (not just initial care and discharge days). CPT 2011 adds three new codes for "subsequent observation care" to facilitate reporting physician services on those "in-between" dates (see box on below for full descriptors).

Example: An internist provides initial observation care to a patient on Tuesday, sees the patient again in observation on Wednesday, and discharges the patient to home on Thursday. In this scenario, code the internist's services as follows:

• One of the initial observation care codes (99218-99220) for Tuesday
• One of the new subsequent observation care codes (99224-99226) for Wednesday
• The discharge service code (99217) for Thursday.