Primary Care Coding Alert

Don't miss revisions to other vaccine, E/M codes.

CPT® 2012 goes into effect in a matter of weeks, so prepare now for new and revised choices related to vaccine administration and prolonged E/M service to ensure your claims stay accurate.

Look for Official Inclusion of 90654

CPT® 2012 adds another choice to your flu vaccine coding with the inclusion of 90654 (Influenza virus vaccine, split virus, preservative-free, for intradermal use). The addition expands on the code family 90655-90668 that already addressed influenza vaccines.

Two factors separate 90654 from many of the other flu vaccine codes:

Code 90654 is not age specific, whereas codes 90655-90658 specify the patient's age (either 6 to 35 months of age, or age 3 years and older).

Code 90654 represents an intradermal injection (administered to the dermal layer of skin), whereas other codes (e.g. 90655-90658 and 90662) describe intramuscular injections (administered to muscle tissue) and intranasal administration (e.g. 90660).

Tip: Code 90654 represents the vaccine product only. Include the appropriate administration code (90460-90474) on your claim. If your physician provides a significant, separately identifiable E/M service during the encounter for the vaccine, also report the appropriate E/M code (99201-99205 for a new patient or 99211-99215 for an established patient).

Although 2012 will be the first time 90654 is included in the CPT® book, the code has been in existence for more than a year. The American Medical Association released 90654 in July 2010 and implemented the code in January 2011. The code achieved FDA approval status in May 2011.

"The CPT® coding process allows for development of new codes and numbers, but they don't become active until FDA approval," explains Richard L. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Heads up: "Most payers won't pay for vaccines until they're FDA approved," Tuck adds. "Even after approval, there can be a lag time from three to six months until payers pick up on the fully approved code."

Note Extra Specificity of 90460-90461

Several other vaccine and vaccine administration codes undergo revision for CPT® 2012. Revised codes include (underline indicates change):

• 90460 -- Immunization administration through 18 years of age via any route of administration, with counseling by a physician or other qualified health care professional; first or only component of each vaccine or toxoid administered. "I believe that 'or only component of each' was added to clarify that you can still use this code if it's a single component vaccine," says Kent J. Moore, manager of healthcare delivery and financing systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. "The previous reference only to 'first' may have confused some people into thinking that 90460 could only be used in a situation where there was both a first and second component."
• +90461 -- ... each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)
• 90581 -- Anthrax vaccine, for subcutaneous or intramuscular use. "I believe 'intramuscular' was added to reflect that alternative mode of administration, which was otherwise missing from the descriptor," Moore says.
• 90644 -- Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine (Hib-MenCY), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use. The descriptor previously included tetanus toxoid conjugate so the vaccine was abbreviated as Hib-MenCY-TT.

In addition, CPT® 2012 deletes vaccine codes 90470 (H1N1 immunization administration [intramuscular, intranasal [including counseling when performed) and 90663 (Influenza virus vaccine, pandemic formulation, H1N1). "These codes were probably considered no longer needed, especially with the addition of codes 90664-90668 in 2011," Moore says.

Learn Timeframes for Observation, Prolonged Care

E/M codes for observation services and prolonged care clarify timeframes and providers with CPT® 2012 revisions.

Observation times: Effective Jan. 1, 2012, each code for initial observation care (99218-99220) specifies the amount of time a physician typically spends at the patient's bedside or on the patient's hospital floor. Code 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components ...) represents 30 minutes, code 99219 represents 50 minutes, and 99220 represents 70 minutes.

Prolonged service: Codes +99354-+99359 delete "physician" and "face-to-face" requirements from the descriptors, which opens the door for other providers in your practice to submit the codes when appropriate. For example, the new descriptor for +99354 will read: Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service).

Track Tobacco Cessation With Revised 4004F

CPT® 2011 introduced a new Category II code for patients who are screened for tobacco use and counseled about tobacco cessation. You'll have a revised version of the code to report when Jan. 1, 2012 rolls around: 4004F (Patient screened for tobacco use AND received tobacco cessation intervention [counseling, pharmacotherapy, or both], if identified as a tobacco user [PV, CAD]).

Background: Category II codes are a set of tracking codes that are intended to be used for performance measurement, according to Denae M. Merrill, CPC, a coder for Covenant MSO in Saginaw, Mich. As such, Category II codes are the "common denominator" for PQRS reporting, so it's in your best interest to report them when appropriate.