Primary Care Coding Alert

Start reporting vaccine administration with office consultation.

The latest update from the Correct Coding Initiative (CCI) brings some limited — but good — news for family physicians: approximately 30 edits involving immunization administration and evaluation and management (E/M) services now have a modifier indicator of 9, meaning that the previous bundles have been deleted and are no longer valid.

The changes took place April 1, 2013 when CCI 19.1 became effective, and the deletion date is January 1, 2013, indicating the change is retroactive to the first of the year.

The explanation for the changes falls under “CPT^® manual or CMS manual coding instructions.”

Six immunization administration codes are part of the reversed edits:

·         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 — … each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure).

You can now report these administration codes in conjunction with any level of inpatient consultation without the necessity of appending a modifier to the inpatient consultation code to get both services paid, says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Ks. The affected codes are:

·         99251 — Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit.

·         99252 — Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making …

·         99253 — Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity …

·         99254 — Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity …

·         99255 — Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity … .

“Unfortunately, the other edits bundling office, outpatient, and preventive E/M services with vaccine administration codes in the absence of a valid modifier remain in place,” Moore notes. “That means you’ll need to continue appending a modifier, such as 25, to an affected E/M code provided at the same encounter as a vaccine administration to get paid for both services under the CCI edits.”

Exception: The one exception is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services.). Code 99211 is bundled with a vaccine administration code, regardless of whether you include a modifier.

Reasoning: The edits, like all of the others bundling E/M and vaccine administration codes, stem from language in the CPT^® guidelines preceding the vaccine administration codes. That language states, “If a significantly separately identifiable Evaluation and Management (E/M) service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes.”

“Because the parenthetical language in CPT^® only refers to office or other outpatient services and preventive medicine services, the edits bundling E/M with vaccine administration only included outpatient and preventive E/M services, except for 99251-99255,” Moore explains. “Note that inpatient hospital and nursing facility visits were not included in the original edits. I think CMS/NCCI realized that the inclusion of 99251-99255 was inconsistent in this regard and rectified the mistake by deleting the edits.”

Recoup: The deletion date for these edits is January 1, 2013, which suggests that the change is retroactive to that date. If you had any services denied on the basis of these particular edits for dates of service between January 1 and April 1, 2013, you may want to consider appealing the denials on the basis of CCI release 19.1.