Primary Care Coding Alert

Tip: Pay special attention to 300+ E/M pairs with influenza vaccines.

Family practice physicians often administer multiple vaccinations during the same encounter, but that doesn’t mean CCI edits allow you to bill for each immunization. Here’s the lowdown on new restrictions to vaccine coding and other items you’ll need to know about from CCI 19.0, effective Jan. 1.

Watch Whether Vaccine Is Reported or Ignored

More than 30 mutually exclusive edits under CCI 19.0 involve pairs of immunization codes – particularly those for influenza and hepatitis. 

A closer look shows that many of the edits involve two influenza codes and do not permit a modifier to override the edit. This is because it would not be clinically appropriate to administer two different influenza vaccines to the same patient on the same date. If you inadvertently report two influenza vaccines for the same patient on the same date, which one will be paid will depend on the pair that you report. For example, new code 90672 (Influenza virus vaccine, quadrivalent, live, for intranasal use) will be paid instead of other influenza vaccine codes 90653 – 90668 if reported with any of them. Note also that several of the codes are pending FDA approval: 

• 90653 – Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use
• 90661 – Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
• 90666 – Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use
• 90667 – Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use
• 90668 – Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use. 

Careful: Some of the same influenza vaccine codes that are a Column 2 code in one edit may be a Column 1 code in other situations. Codes 90654-90668, for example, will always be paid instead of 90653 if listed for the same patient on the same date of service. 

Hepatitis look: Edits also clarify that some hepatitis vaccines should not be administered (and reported) on the same day as other hepatitis vaccines. For instance, based on the CCI edits, physicians should not administer hepatitis B vaccine 90739 (Hepatitis B vaccine, adult dosage [2 dose schedule], for intramuscular use) during the same encounter as the following hepatitis vaccines: 

• 90636 – Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use
• 90723 – Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use 
• 90740 – Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
• 90743 – Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
• 90744 – Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
• 90746 – Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
• 90747 – Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
• 90748 – Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use. 

“Like the influenza vaccine edits above, these edits make sense clinically. In each case, the Column 1 code already includes the Hepatitis B vaccine, and there is no clinical indication for administering two Hepatitis B vaccines to the same patient on the same date,” states Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Ks. 

Check E/M Services as Column 2 Codes for Administration 

Non-mutually exclusive edits in CCI 19.0 list approximately 300 pairs involving E/M services and immunization administration. The administration code is always listed in Column 1: 

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)
• 90473  –  Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
• +90474  –  Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure). 

The route of administration overrides E/M services for a new or established patient’s office visit (99201-99215), office consultation (99241-99245), inpatient consultation (99251-99255), ER visit (99281-99285), preventive medicine services for a new or established patient (99381-99397), and preventive medicine counseling services (99401-99420). These new edits are an extension of a similar edit that has been in existence for much longer. Namely, CCI has historically prevented reporting code 99211 on the same date for the same patient as a vaccine administration code. The idea behind the edits is that an E/M service provided at the same encounter as a vaccine administration should be a significant and separately identifiable service. Vaccine administration by itself does not merit both the administration code and an E/M service. 

Caveat: All the applicable edits are classified as such because of CPT® manual or CMS manual coding instructions. However, with one exception, they each carry a modifier indicator of “1.” That means if the situation merits separate reporting and you have supporting documentation, you can potentially append a modifier (such as 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) to the E/M code and report both services. The one exception is E/M code 99211. The modifier indicator in that instance is “0,” which means CCI will not let you use a modifier to report both 99211 and a vaccine administration code for the same patient on the same date; if you do, only the vaccine administration code will be recognized. 

CCI 19.0 includes more than 37,500 new edits. The edits listed here should apply to every family physician, but others might as well. Cull through the file yourself to see if other edits will affect your practice.