Ob-Gyn Coding Alert

Find out which E/M code most payers won't separately reimburse

If your ob-gyn practice is interested in administering the new HPV vaccine, you should start getting acquainted with 90649. But be forewarned -- due to limited coverage, your patients may have to pay $360 out-of-pocket.

First, Familiarize Yourself With the Vaccine

What it is: The human papillomavirus (HPV) is a major risk factor for preinvasive and invasive cervical cancer. The newly approved vaccine works by preventing infection by four of the dozens of HPV strains, the most prevalent sexually transmitted disease.
 
You-ve already got a code for the vaccine, thanks to CPT 2006. -You may have noticed the lightning bolt in front of 90649 (Human papillomavirus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use). That symbol means you cannot use this code until the Food and Drug Administration gives its approval,- says Melanie Witt, RN, CPC-OGS, MA, an ob-gyn coding expert based in Guadalupita, N.M. -The good news is that on June 8, the FDA officially licensed the vaccine for use in girls and women ages 9 to 26.-

Get a Clear Picture of Your Vaccine Claim

When your ob-gyn administers the HPV vaccine, you should use 90649, which  covers types 6, 11, 16 and 18 on a three-dose schedule. You should report 90649 three times during a six-month period.
 
Your diagnosis should be V04.89 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases), says Patricia Larabee, CPC, CCP, an ob-gyn coding specialist at InterMed in South Portland, Maine.
 
You should also report 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the vaccine administration.
 
Your diagnosis will be V04.89 for this code as well. 

Get the Modifier Low-Down

The good news is that CPT guidelines state you should not append modifier 51 (Multiple procedures) to either 90649 or 90471.
 
Also, if your ob-gyn provides a significant and separate E/M service during the same visit that she administers the vaccine, you may also bill an E/M code with modifier 25 (Significant, separately identifiable E/M  service by the same physician on the same day of the procedure or other service) appended to inform the payer that the E/M service was separate.
 
Keep in mind: Almost all payers will not pay separately for 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem[s] are minimal -) plus an injection procedure because this E/M code represents a minimal, not significant, E/M service, Witt says.
 
Cover Your Bases With Payers

Until the Centers for Disease Control comes out with a recommendation for the vaccine, coverage is going to be a problem. 
 
Insurance plans will cover the cost of the vaccine, but only if the CDC's Advisory Committee on Immunization Practices (ACIP) recommends this vaccine as a standard. -Until then, you may want to advise your patients who are candidates for the vaccine that this may be an out-of-pocket expense for them,- Witt says.
 
Merck, the company that produces the vaccine, states that the price will be $120 per injection ($360 for the required series of three). The company has also indicated that it has created a new patient assistance program for vaccines. This means it will provide free vaccines, including the new HPV vaccine, to adults who are uninsured and who are unable to afford it. 
 
-Because the FDA approved the vaccine on June 8, it is too soon to know if commercial payers are going to jump on board and cover it prior to an ACIP decision,- Witt says. -All the coverage documents I reviewed specifically state they will not cover the HPV vaccine.-