Internal Medicine Coding Alert

Use different administration codes for Medicare patients.

When your internal medicine specialist provides a pneumococcal vaccine to a patient, report the appropriate vaccine code and the administration code depending on the age of the patient and counseling provided. Understand the new coverage criteria for Medicare patients that allow for revaccination a year after the first vaccination.

Select Appropriate Vaccine Code Based on Type Used

When reporting an administration of pneumococcal vaccine, choose the appropriate code for the vaccine depending on the type of vaccine used. Based on these criteria, you have three choices to appropriately report the type of vaccine that was used on the patient:

• 90669 (Pneumococcal conjugate vaccine, 7 valent, for intramuscular use)
• 90670 (Pneumococcal conjugate vaccine, 13 valent, for intramuscular use)
• 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use)

Don’t Forget to Additionally Report Administration Code

While the above mentioned CPT® code choices are used to choose the type of pneumococcal vaccine that was administered to the patient, you will also have to report an administration code. You will choose the appropriate code for the administration based on the age of the patient. When administered in young patients, you will also have to check documentation to see if additional counseling was provided to the patient or the parents of the patient about the vaccine being administered.

Based on the age of the patient and counseling provided, you have the following CPT® code choices to report from to cover the administration of the pneumococcal vaccine:

90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered)

• +90461 (…each additional vaccine or toxoid component administered [List separately in addition to code for primary procedure])
• 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid])
• +90472 (…each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure])

Reminder: You will report the add-on codes +90461 or +90472 only in cases where other vaccines or components were also provided to the patient during the same visit and not as primary codes when only the pneumococcal vaccine was administered.

Use Different Administration Code For Medicare Patients

When your clinician administers pneumococcal vaccine to a Medicare patient, you will have to report an appropriate HCPCS code for the administration and not the above mentioned CPT® codes. For Medicare patients, pneumococcal vaccine administration should be reported with G0009 (Administration of pneumococcal vaccine).

Coverage guidelines: According to Medicare guidelines, administration of pneumococcal vaccine has historically been covered for patients who are at high risk of pneumococcal disease. The persons who are considered high risk for pneumococcal disease include:

• People 65 years of age or older
• People who are suffering from a chronic illness (such as diabetes, cardiovascular problems, pulmonary diseases, alcoholism, cirrhosis, etc.) that put them at high risk of contracting pneumococcal disease
• People who suffer from compromised immune systems (e.g. due to an illness such as Hodgkin’s disease, lymphoma, chronic renal failure, nephrotic syndrome, people who have had an organ transplant, HIV, etc.)

Those guidelines mentioned that a person should be provided the pneumococcal vaccination only once during their lifetime. Medicare stated that the patient need not be revaccinated unless the person has the highest risk of serious pneumococcal infection or there was a likelihood of a rapid decline in the level of pneumococcal antibody levels. This revaccination was to be done only after five years had passed since the previous administration.

New guidelines: According to the transmittal R202BP andR3159CP, change request 9051 that was issued September 19, 2014, CMS has changed some guidelines for pneumococcal vaccines to align with recommendations provided by the Advisory Committee on Immunization Practices (ACIP). These changes are effective for pneumococcal vaccine dates of service on or after Sep. 19, 2014.

“Although the changes are effective for dates of service on or after Sep. 19, 2014, they won’t be implemented until Feb. 2, 2015, according to CMS,” observes an expert. “Medicare administrative contractors will not search for and adjust any pneumococcal vaccine claims dated on or after Sep. 19, but they may adjust such a claim if the physician brings it to their attention.” According to these new guidelines, Medicare will cover:

• An initial pneumococcal vaccine to all Medicare beneficiaries who have never received the vaccine under Medicare Part B; and
• A different, second pneumococcal vaccine one year after the first vaccine was administered (that is, after 11 full months have passed following the month in which the last pneumococcal vaccine was administered).

“Note that the interval between the two different pneumococcal vaccines must be more than 11 months for Medicare coverage, not eight weeks or six months as recommended by the ACIP,” he points out. 

But, going by the new guidelines set, your clinician may revaccinate a person after a year has passed by from the time of the first administration. But, the two vaccines should not be of the same type. 

There is no need for your clinician to review the patient’s complete medical history nor is it mandated by Medicare and, likely, most other payers for the patient to provide a complete immunization record prior to you clinician providing the vaccine. It is thoroughly acceptable for the patient to provide a verbal history (if the patient is competent) to enable your clinician to determine immunization status. However, your clinician should ideally have access to the patient’s previous vaccination history to determine the necessity of providing the vaccination as well as to know the nature of the previous vaccination, so the clinician can ensure the subsequent vaccination is of a different type.

Example: Your internist had administered the 23-valent pneumococcal polysaccharide vaccine (PPSV23) to a 66-year-old Medicare patient on Oct. 1, 2013. The patient returned to your internal medicine on Oct. 15, 2014. Since a year had passed since the first administration of PPSV23, your physician administers the 13-valent pneumococcal conjugate vaccine (PCV13).

For more information on pneumococcal vaccination, check this link at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf and for information on the newly introduced guidelines, check the MLNMatters article at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9051.pdf.