Practice Management Alert

Caveat: You're already using both the code and the modifier.

You may be cheering the addition of a new flu vaccine code and a new modifier in CPT® 2012, but once you read the fine print, the "new" code may reflect "old" news.

Find 90654 in the 2012 Manual

The AMA introduced code 90654 (Influenza virus vaccine, split virus, preservative-free, for intradermal use) effective Jan. 1, 2011, but it was too late to make it into the 2011 CPT® manual, says Jill M. Young, CPC, CEDC, CIMC, with Young Medical Consulting LLC in East Lansing, Mich. Therefore, the code makes its first appearance in CPT®2012, even though you've probably already reported it.

Background: Even though the code was added "effective January 1, 2011," it didn't become payable by Medicare until May 9, 2011, MLN Matters article 7580 explains. In fact, MACs didn't reimburse for 90654 until May 9, 2011, notes article MM7580, which came out on Oct. 28. To read the entire article, visit (www.cms.gov/MLNMattersArticles/downloads/MM7580.pdf.)

Check it out: CMS has already assigned a relative value to 90654 -- this flu season, you'll collect $18.383 in Medicare-equivalent payment for the preservative-free split virus for intradermal use.

Tackle Preventive Services With Modifier 33

Also, you'll see modifier 33 (Preventive services) printed in your CPT® manual. It, too, went into effect Jan. 1, 2011. This modifier allows you to tell your payer that you performed a preventive service and that the patient's deductible and coinsurance do not apply under the new Patient Protection and Affordable Care Act (PPACA) rules.

Downside: Unfortunately, you're not likely to get any love from your MACs with this new modifier. According to a Q&A on WPS Medicare's Web site, Medicare does not recognize modifier 33 (www.wpsmedicare.com/part_b/resources/provider_types/awv-faq.shtml).

The reason? Medicare can only pay for preventive services that are specifically legislated and all of these services have their own "G" codes to describe them. You can only place modifier 33 on a CPT® code.

Some insurers, such as Excellus BlueCross BlueShield, have information regarding modifier 33 on their Web sites. For example, Excellus shares several guidelines for reporting modifier 33, including:

• CPT® modifier 33 is applicable to preventive services that do not have a unique code for such services (e.g., E&M codes such as, 99401 would not require modifier 33 as this code already indicates a preventive medicine service. However, code 99213 would require modifier 33 when the provider indicates that the service was preventive).
• If multiple preventive medicine services are provided on the same day, then the modifier is appended to the codes for each preventive service rendered on that day.
• Modifier 33 should be used when only preventive services were rendered on that date, not when combined with other non-preventive services.
• CPT® codes identified as inherently preventive, (e.g., screening mammography) should not be appended with modifier 33.

Sometimes, we must educate the payers just like we sometimes must educate ourselves and our physicians. Check for information about modifier 33 on other payer Web sites or through the AMA Web site (www.ama-assn.org/resources/doc/cpt/new-cptmodifier-for-preventive-services.pdf).