Primary Care Coding Alert

Age, Counseling Determine Code Selection

The new codes (90465-90468) don't replace the old codes (90471-90474). In fact, you'll use all eight codes. "The new vaccine codes will help you obtain reimbursement for cases in which an FP spends a lot of time explaining and answering questions, especially to new parents," says Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City.

Starting Jan. 1, you should choose the right code set based on the encounter. Report the new codes (90465-90468) when the encounter meets two criteria:

1. the child is under age 8

2. the FP performs face-to-face vaccine counseling regarding vaccine product, possible reaction and addressing parental concerns.
 
If the vaccine administration doesn't meet the age and physician requirements, you would assign the old codes (90471-90474).

Payer example: A nurse counsels a 6-year-old child's mother on vaccine benefits, risks and reactions and has the mother sign the consent form. In this case, you wouldn't use the new codes, Walsh says. "You instead will revert to the old codes."

Why: The encounter doesn't meet both new code requirements. The 6-year-old meets the age requirements, but because the nurse does the counseling, the encounter doesn't qualify as 90465-90468.

You'll Usually Rely on Old Code With the Elderly

Remember, most Medicare patients won't meet 90465-90468's age requirement. So, you'll typically submit the old codes when your FP administers a shot to a Medicare patient.

Medicare carrier scenario: After suffering a puncture wound from a contaminated nail while working outside, a 65-year-old Medicare patient requires a tetanus booster shot. The FP counsels the man on the vaccine benefits, risks and possible side effects. In this example, you should code the encounter the same way you now do, with 90471-90474.

Reason: The scenario lacks 90465-90468's criteria. The patient is older than the new codes' age requirement, so the encounter doesn't warrant payment for increased physician counseling work.

Payment Is Around the Corner

To receive payment when the encounter qualifies for work relative value units (RVUs), you may have to nudge payers to recognize the new vaccine administration codes.

Private insurers recently started recognizing 90471-90474, which CPT 1999 introduced and CPT 2000 clarified. Payers may reject the new codes, thinking that the coder reported the wrong two last digits.

Payment tip: When CMS publishes the 2005 National Physician Fee Schedule Relative Value File, use the tool as a weapon for private payers. Send insurers a copy of the fee schedule showing the relative value units that Medicare assigns to 90465-90468.

CMS Eliminates Grace Period

For Medicare and Medicaid carriers, make sure you start submitting the new codes for applicable vaccine administration on Jan. 1.

CMS discontinued the 90-day grace period practices previously had to implement the new code set. You must report the HCPCS code that is valid at the time of service.

Private payers may adopt this guideline, which CMS based on HIPAA. Look for a notice from insurers. "Most regular billing managers can handle adjusting their billing systems," says Jane M. Dodds, MPH, FACMPE, former president of the Medical Group Management Association's Primary Care Assembly. But hospitals or other large groups might have problems.