Primary Care Coding Alert

Look for updated reporting instructions from CMS.

The CPT^® Editorial Panel has approved the addition of three new monkeypox codes, including one testing code and two vaccine product codes. These new codes took effect in late July 2022 to address the rise of monkeypox cases nationwide. Keep reading for guidance on how to use these codes in your practice.

Check Out This Condition Definition

“Monkeypox is caused by monkeypox virus, a member of the Orthopoxvirus genus in the family Poxviridae,” according to the World Health Organization (WHO). It’s usually a self-limited disease with a fatality ratio of around 3-6 percent. Standard smallpox vaccines provided protection against monkeypox, even back during the eradication program in the 1970s, but the Food and Drug Administration (FDA) responded to the recent monkeypox outbreak with a newer vaccine (www.who.int/news-room/fact-sheets/detail/monkeypox).

Familiarize Yourself With the Codes

The following codes are effective immediately and will be included in the CPT^® 2023 code set, but you may not see them in the American Medical Association (AMA) code book until CPT^® 2024 because of publishing dates. You’ll be able to find them in the Microbiology subsection of the Pathology and Laboratory section and in the Vaccines, Toxoids subsection of the Medicine section, respectively.

• 87593 (Infectious agent detection by nucleic acid (DNA or RNA); orthopoxvirus (eg, monkeypox virus, cowpox virus, vaccinia virus), amplified probe technique, each)
• 90611 (Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use)
• 90622 (Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use)

Use 87593 to streamline tracking and reimbursement: Like they have been during the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) requires providers to track monkeypox testing. This is for the purpose of safety monitoring as well as general knowledge of where the infections are spreading. The existence of this new orthopoxvirus testing code allows for accurate reporting to meet the needs of the CDC.

If the patient tests positive for monkeypox, report diagnosis code B04 (Monkeypox).

Use 90611 for patients 18 years or older: Code 90611 describes the JYNNEOS combined smallpox and monkeypox vaccine that’s administered in two doses and has FDA approval for patients 18 years and older at high risk for smallpox or monkeypox infection. Supply is limited, so be sure your documentation includes information that supports the need for patient prioritization, such as those with human immunodeficiency virus (HIV) or other severely immunocompromising conditions.

Use 90622 for patients 12 months and older: The FDA has approved the ACAM2000 smallpox vaccine product for single-dose use in patients 12 months and older. The expanded access Investigational New Drug (IND) application allows its use against monkeypox. In other words, the FDA is allowing the “compassionate use” of investigational new drug products outside of clinical trials, in this case ACAM2000, to expand access for certain patients who have no alternative options.

Remember to Use the Existing Vax Admin Codes

“The new codes for smallpox and monkeypox vaccine only include the product itself. As with other vaccines, the administration is reported with a separate CPT^® code,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. There are currently no new administration codes for 90611and 90622, which means you should use the following codes when your provider administers the vaccines to your patients:

• 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))

Note: Pay close attention to the descriptors when selecting the correct administration code. Age, administration method, and provider qualifications are going to dictate which code(s) you’ll need.

Clear Up Confusion About Which Codes to Report

On Aug. 11, 2022, the Centers for Medicare & Medicaid Services (CMS) told you to bill only for vaccine administration when your practice received the vaccine product from the government for free. However, on Sept. 1, 2022, CMS updated their instructions for what you should include on a vaccine administration claim. The new instructions say to include the following three elements on your claim, even if your practice obtained the vaccine from the government for free (www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2022-09-01-mlnc#_Toc112853229).

1. Product code (90611 or 90622)
2. Applicable ICD-10-CM diagnosis code
3. Administration code

“The ICD-10-CM diagnosis code associated with immunization administration is Z23 (Encounter for immunization),” says Moore. CMS will address the no-cost product payment adjustments on your remittance advice.

E/M coding alert: Whether to report an E/M separate from the vaccine administration depends on what happened during the encounter and how thoroughly the provider documented it. Counseling related to the vaccine is bundled within 90460 and +90461. “That time should not be counted when reporting an E/M service using a code from the Office or Other Outpatient Service E/M codes (99202-99215) based on time, since that would constitute double counting and thus double billing,” cautions Moore.

However, let’s say after receiving the vaccine the patient reports irritating foot pain that’s been waking him up in the middle of the night. The physician then gathers information, does a thorough evaluation, and discusses possible causes with the patient. The doctor suspects plantar fasciitis, discusses the different management options, and suggests an over-the-counter pain management regimen along with a series of daily foot exercises and follow-up appointment in two weeks.

In encounters like this, as long as the evaluation and the management of the problem was documented as being separate and significant, append modifier 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 office/ outpatient E/M service code, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient… straightforward medical decision making. When using time for code selection…).