Medicare Compliance & Reimbursement

Tip: Don’t forget about two crucial coding exceptions.

As the nation heads into a third coronavirus wave in the midst of flu season, you may have patients swarming your office requesting flu vaccinations and evaluations. Now is a good time to refresh your procedure coding checklist to sidestep both compliance and reimbursement woes.

Understanding the “new” and “established” patient nuances is at the heart of clean immunization claims. Boost your coding prowess with three frequently asked questions (FAQ) and answers from the experts.

Question 1: If a patient comes in for a vaccination only, are they considered an established patient to the practice from that point on?

Answer: At this time of year, many Medicare providers offer flu clinics, where the only service the practice offers is a flu shot to patients. Under these circumstances, it may be tempting to think that administering the immunization to a patient who is new to the practice automatically makes the patient established. This critical distinction could result in the practice losing revenue associated with the extra work required by a new patient — should that patient return to the practice for a subsequent sick or well visit. In fact, the kind of immunization service the practice provides will determine the patient’s status to the practice.

Why? Codes 90471/+90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) …) and 90473/+90474 (Immunization administration by intranasal or oral route …) are generally, though not always, administered by clinical staff such as medical assistants, licensed practical nurses, and registered nurses, rather than physicians or qualified healthcare professionals (QHPs).

Tip: Remember that CPT^® defines a QHP as “an individual who is qualified by education, training, licensure/regulation [when applicable], and facility privileging [when applicable] who performs a professional service within his/her scope of practice and independently reports that professional service.”

When this happens, and immunization services 90471-+90474 are administered by clinical staff, the services “do not qualify as a professional service and therefore the codes do not fulfill the requirement for establishing the patient to the physician and/or practice,” suggests Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

In other words, once a patient has received one of these services, they may still be regarded as new to the practice because the service was not a face-to-face service rendered by a physician or qualified healthcare professional. This means “your provider can bill a new patient visit when the patient is seen subsequently for a sick visit or well visit following these nurse-visit only services, though payers may have their own rules, which may not be consistent with CPT^® guidelines,” Walaszek advises.

Exception: CPT^® lists one other immunization administration service: 90460/+90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; …). Unlike 90471/+90472 and 90473/+90474, 90460/+90461 are regarded as professional services, because a physician or a QHP must counsel the patient or the patient’s caregiver about the vaccination to report the service. This means that any patient receiving such services from the same provider or another provider within the same specialty in a group practice within a three-year period must be regarded as established to the practice.

Question 2: Can vaccine administration be reported separately from other services?

Answer: If the provider performs a “significant separately identifiable” E/M service such as 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) or 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual …), “the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes” 90460/+90461, 90471/+90472, and 90473/+90474, according to CPT^® guidelines.

Reminder: If vaccine administration does occur at on the same date of service as an E/M service, modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health care Professional on the Same Day of the Procedure or Other Service) must be appended to the E/M. Absent this modifier, payment for the E/M code will be bundled into the vaccine administration for those payers following National Correct Coding Initiative (NCCI) edits.

Exception: Per NCCI, “90460 cannot be billed in conjunction with 90471-+90474, and no modifier is permitted with any of these code pairs. If billed together, only 90460 will be paid. Also, per NCCI edits, 99211 is a component code of 90460, +90461 and 90471-+90474, and no modifier is permitted with this code pair as well,” Walaszek warns. Only the vaccine administration code, not 99211, would be paid in that situation.

Question 3: In encounters where a provider administers different vaccine routes, do I report the base vaccine codes for each route?

Answer: The descriptors for both +90472 and +90474 direct you to list the codes separately “in addition to code for primary procedure.” Also, the parenthetical note following both codes indicates they may be reported in conjunction with any of the base codes.

This means only one base code is typically reported, even when different routes of administration are involved. So, “if your clinician orders one vaccine intramuscularly and other vaccine(s) intranasally or orally, the second, third, and any subsequent vaccine administrations are always assigned the add-on codes appropriate for the route of administration,” according to Barbara J. Cobuzzi, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare Solutions in Tinton Falls, New Jersey.