Primary Care Coding Alert

Be careful: Some codes switch from acceptable to non-reportable.

You now have more details to consider when coding for multiple vaccines during a single patient encounter, thanks to the Correct Coding Initiative. CCI edits (version 18.2) went into effect July 1, with vaccine administration being the biggest focus for family physicians.

Watch Vaccine Coding So You Don't Double Dip

Mutually exclusive edits under CCI identify code pairs that Medicare has determined are unlikely to be performed on the same patient on the same day. Because of this, the pairs carry an associated modifier indicator of "0," so coders won't try to break the edit and report both procedures.

CCI 18.2 confirms that providers normally shouldn't administer certain vaccines to a patient on the same day. In the event of both vaccines being administered, you submit the procedure listed in Column 1 of the pair. Some of the vaccinations are the Column 1 (reportable) procedure in some pairs, but the Column 2 (non-reportable) procedure in other pairs.

The following table illustrates the latest sets of vaccines you shouldn't report together.

Explanation: In each case of the above edits, the Column 2 code duplicates all or a portion of the Column 1 code. For example, 90664 and 90667 are both influenza vaccines, and there is no clinical rationale supporting a physician administering two influenza vaccines to the same patient on the same date. Therefore, the codes are mutually exclusive.

Note: If you do submit two mutually exclusive services on the same claim, CMS will only reimburse for the service in Column 1.

Skip G0442, G0443 in Favor of Larger Exam

The other type of CCI edits are categorized as non-mutually exclusive. These edits represent procedures that CMS has determined physicians should not bill together because one service inherently includes the other. The pairs are also known as bundled services, or comprehensive/component edits.

CCI 18.2 includes four non-mutually exclusive edits that could pertain to family physicians. When the physician or NPP completes a work-related or medical disability examination represented by 99455 or 99456, Medicare believes the service includes a screening or brief counseling regarding alcohol misuse. Thus, CCI 18.2 indicates that you shouldn't normally submit G0442 (Annual alcohol misuse screening, 15 minutes) or G0443 (Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes) with 99455 or 99456.

Exception: The edits carry a modifier indicator of "1," meaning that you might be able to report -- and be paid for -- both codes under certain circumstances. If so, you would append a modifier (such as modifier 59, Distinct procedural service) to the G0442 or G0443 to indicate the counseling or screening was a separate service from the more comprehensive exam.

Resource: CCI 18.2 includes 160 new mutually exclusive edits and 2,239 new non-mutually exclusive edits, according to an analysis by Frank Cohen of The Frank Cohen Group in Clearwater, Fla. Visit the CCI page on CMS's website to download the complete set of edits (http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html).