Internal Medicine Coding Alert

Influenza vaccines to be based on dosage.

If you have been thinking about what CPT® 2017 has in store for you, here is a sneak peek. As with every year, you should expect to see some changes to vaccination codes that you have been using. In addition, you will probably see a total overhaul to moderate (conscious) sedation codes.

Track Changes to Vaccination Codes

As with every year, you will see some changes to vaccination codes in CPT® 2017. For instance, you will see a new code, 90674, introduced for quadrivalent influenza virus vaccine that is derived from cell cultures, is preservative free and antibiotic free, and is intended for intramuscular use.

With the advent of code 90674 for quadrivalent influenza virus vaccine derived from cell cultures, you will see a change in the descriptor to the existing code for influenza virus vaccine derived from cell cultures. Specifically, you will see the term “trivalent” added to the descriptor to 90661. The new (2017) descriptor for this code will read, “(Influenza virus vaccine, trivalent [ccIIV3], derived from cell cultures, subunit, preservative and antibiotic free, 0.5mL dosage, for intramuscular use.”

Apart from seeing one new code for influenza virus vaccine, you will also see some descriptor changes to existing influenza vaccine codes. According to the proposed change, you will see “age descriptors” such as “when administered to children 6-35 months of age” and “when administered to individuals 3 years of age or older” removed from many of the existing codes. 

Instead of these “age descriptors,” you will see the introduction of “dosage description” for these codes. If these changes are implemented, you will need to check the dose of the vaccine that the physician administered to arrive at the right code to report for the vaccine. The proposed change substitutes “0.25 mL dosage” for “6-35 months of age” in influenza vaccine codes with age descriptors, and it substitutes“0.5 mL dosage” for “3 years or older.”  These changes impact codes 90655-90658 and 90685-90688. 

Impact: Since the descriptors will now carry dosage specifications in lieu of age, the age of the individual will not help you decide on the code that you will have to use. “Age doesn’t always describe a patient thoroughly. Having dosing associated with the codes will help paint a more accurate picture as to what each patient is getting,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC,of ACE Med Group in Pittsburgh, Pa. 

For instance, until now, you had to use either 90685 (Influenza virus vaccine, quadrivalent [IIV4], split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use) or 90686 (…3 years of age and older…) when a clinician administered quadrivalent, preservative free, split virus influenza vaccine. If the proposed changes are implemented, you can use 90685 even for older individuals if your internal medicine specialist administers a 0.25 mL dosage to the patient instead of using 0.5 mL dosage. “If you had a very tiny 20 year old, a child’s dose might be more appropriate. But, the insurance company could have rejected the claim if it was billed as a child dose for a 20 year old,” Hauptman adds. “Conversely if you have a 12 year old who is very tall and weighs 200 pounds, the doctor might choose to give a larger dose that would not be appropriately matched with a child’s dosing code.”

There are two other new vaccine codes that are effective Jan. 1, 2017, but won’t appear in the CPT® manual until 2018. Both codes represent vaccines that are pending approval by the Food and Drug Administration (FDA). The new codes are:

90682 (Influenza virus vaccine, quadrivalent [RIV4], derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use)

90750 (Zoster (shingles) vaccine [HZV], recombinant, sub-unit, adjuvanted, for intramuscular injection).

Note that there are two other vaccines that have received FDA approval, and the corresponding CPT® codes will reflect that fact in the 2017 manual. These codes are 90653 (Influenza vaccine, inactivated [IIV], subunit, adjuvanted, for intramuscular use) and 90625 (Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use).

Moderate Sedation Codes Can Be Overhauled

Going by the proposed list of changes, it is likely that you will have to completely remove the currently existing set of codes for moderate (conscious) sedation. So, if the changes come into force, you will no longer be using 99143-99150 when reporting moderate sedation services. All these codes will transform into a new list of codes.

According to the proposed list, these codes will have a few tweaks to its descriptors. In the new set of codes proposed, you will have to report the base codes for the first 15 minutes of intra-service time instead of the 30 minutes of intra-service time that is being currently used. 

Impact:  If the proposed changes come to effect, you will see base moderate sedation codes such as 99148 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years ofage, first 30 minutes intra-service time) being replaced with a new code that is reported for the first 15 minutes of intra-service time. Since the base codes are being replaced by a code that is reported for a lesser duration of time, you are most likely to see some changes in the form of reductions to the relative value units (RVUs) that each of these codes are allocated.

However, the new add-on codes contain the same time duration as is listed in the current code set that is being used. So, you will probably see no changes to the way additional intra-service time is being reported currently.

Resources: For more information on the changes to influenza vaccines, check this link at https://download.ama-assn.org/resources/doc/cpt/x-pub/vaccine-code-desc.pdf.

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