Primary Care Coding Alert

Use different administration codes for Medicare patients.

When your FP provides a pneumococcal vaccine to a patient, report the appropriate vaccine code and the administration code depending on the age of the patient and counseling provided. Also, make sure you understand the new coverage criteria for Medicare patients that allow for revaccination a year after the first vaccination.

Select Appropriate Vaccine Code Based on Type Used

For pneumococcal vaccines, you’ll choose the appropriate code depending on the type of vaccine used. Based on these criteria, you have three choices to appropriately report the type of vaccine that was used on the patient:

• 90669 (Pneumococcal conjugate vaccine, 7 valent, for intramuscular use)
• 90670 (Pneumococcal conjugate vaccine, 13 valent, for intramuscular use)
• 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use)

Don’t Forget to Additionally Report Administration Code

While the above mentioned CPT® code choices are used to choose the type of pneumococcal vaccine, you will also have to report an administration code. Select the appropriate code for the administration based on the age of the patient. When administered in young patients, you will also have to check documentation to see if additional counseling about the vaccine was provided to the patient or the parents of the patient. Based on the age of the patient and counseling provided, you have the following CPT® code choices for pneumococcal vaccine administration:

• 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])
  

“Although the changes are effective for dates of service on or after Sep. 19, 2014, they won’t be implemented until Feb. 2, 2015, according to CMS,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Medicare administrative contractors will not search for and adjust any pneumococcal vaccine claims dated on or after Sep. 19, but they may adjust such a claim if the physician brings it to their attention.”

“Note that the interval between the two different pneumococcal vaccines must be more than 11 months for Medicare coverage, not eight weeks or six months as recommended by the ACIP,” points out Moore.

But, going by the new guidelines set, your clinician may revaccinate a person after a year has passed by from the time of the first administration. But, the two vaccines should not be of the same type.

There is no need for your clinician to review the patient’s complete medical history nor is it mandated by Medicare and, likely, most other payers for the patient to provide a complete immunization record prior to your clinician providing the vaccine. It is thoroughly acceptable for the patient to provide a verbal history (if the patient is competent) to enable your clinician to determine immunization status. However, your clinician should ideally have access to the patient’s previous vaccination history to determine the necessity of providing the vaccination as well as to know the nature of the previous vaccination, so the clinician can ensure the subsequent vaccination is of a different type.

Example: Your FP had administered the 23-valent pneumococcal polysaccharide vaccine (PPSV23) to a 66-year-old Medicare patient on Jan. 10, 2014. The patient returned to your FP on Feb. 5, 2015. Since a year had passed since the first administration of PPSV23, your FP administers the 13-valent pneumococcal conjugate vaccine (PCV13).

Resource: For more information on pneumococcal vaccination, check this link at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf and for information on the newly introduced guidelines, check the MLNMatters article at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9051.pdf.