2015 Coding and Reimbursement Survival Guide Chapter 6: Family Practice CPT 2015 Update: Get Ready to Inject Your 2015 Vaccine Claims With New, Revised CPT Codes Check out new additions to arthrocentesis procedures that involve guidance. If you have been wondering at what new changes you will be facing with CPT 2015, here is a first look at what you can expect. You will be seeing some new codes for vaccinations, arthrocentesis, and chronic care management while having to take into account some descriptor changes to old codes. Observe Changes to Vaccination Codes As with every year, you will be seeing some changes to vaccination codes in CPT 2015. You will have to add two new vaccine codes to your cache while making note of many changes to the descriptors of old codes. The two new codes that you will be seeing in 2015 include: 90630 (Influenza virus vaccine, quadrivalent [IIV4], split virus, preservative free, for intradermal use) 90651 (Human Papilloma virus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent [HPV], 3 dose schedule, for In addition, you will be seeing the following descriptor changes in CPT 2015: 90654 (Influenza virus vaccine, trivalent [IIV3], split virus, preservative-free, for intradermal use) 90721 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib)[DTaP/Hib], for 90723 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitishepatitis B, and inactivated poliovirus vaccine, inactivated (DtaP-HepB-IPV) [DTaP-HepB-IPV], for 90734 (Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), quadrivalent, for intramuscular use) Note: The new codes, 90630 and 90651, carry the lightning bolt (~) sign that indicates that these codes are still awaiting FDA approval. The revisions to the existing codes are primarily editorial or otherwise made to distinguish the existing codes from new codes that will appear in 2015, observes Kent Moore, senior strategist for physician payment with the American Academy of Family Physicians. For instance, the addition of the word trivalent to 90654 is primarily for the purposes of distinguishing it from new code 90630, which is a quadrivalent vaccine, Moore adds. Watch Out For Changes to Arthrocentesis Codes According to the proposed changes to CPT codes in 2015, you will be seeing some changes to the descriptors of codes that you would use to report arthrocentesis. You will also have to take into account some new codes being introduced for these procedures when they involve ultrasound guidance.
The descriptor changes and the new codes that you will see for arthrocentesis include: 20600 (Arthrocentesis, aspiration and/or injection, small joint or bursa [e.g., fingers, toes]; small joint or bursa (eg, fingers, toes)without ultrasound guidance) 20604 ( with ultrasound guidance, with permanent recording and reporting) 20605 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa];intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)without ultrasound guidance) 20606 ( with ultrasound guidance, with permanent recording and reporting) 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa [e.g., shoulder, hip, knee, subacromial bursa]; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa)without ultrasound guidance) 20611 ( with ultrasound guidance, with permanent recording and reporting) Coding tip: You will have two different codes for any arthrocentesis procedure depending on whether or not your clinician used ultrasound guidance for placement of the needles in the joint. So, you will have to look at documentation to ascertain the use of ultrasound guidance to arrive at the right CPT code for the procedure performed. Note that the new arthrocentesis codes with imaging guidance only refer to ultrasound guidance, Moore points out. If your family physician uses some other sort of imaging guidance, that remains separately reportable, as it is now. Embrace the Chronic Care Management Improvements Changes to five CCM codes may make your chronic care management services coding less of a chore. You ll find that CPT 2015 revises the descriptor for 99487 with bulleted detail as follows: (Complex chronic care coordination management services, with the following required elements: multiple [two or more] chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; establishment or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month In addition, you ll see that CPT 2015 deletes 99488 (Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month). Don t miss: For each additional 30 minutes of chronic care management your physician provides, you will still be able to report revised add-on code +99489 (Complex chronic care coordination management services...; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month [List separately in addition to code for primary procedure]). Bonus: You will also have two new CCM codes to choose from: 1. 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
comprehensive care plan established, implemented, revised, or monitored 2. +99498... each additional 30 minutes... These changes appear to be primarily in response to the Centers for Medicare & Medicaid Services (CMS) proposal to establish its own G code for chronic care management along the lines described in code 99490, Moore says. It will be interesting to see what CMS decides to do with its proposal in light of the CPT changes. Medicare Immunizations: Ensure Tetanus Vaccine Coding Success With This Expert Advice Hint: Report appropriate diagnosis codes to avoid denials. When your clinician administers tetanus vaccine to a patient, you will have to focus on whether or not the encounter meets coverage criteria. If coverage criteria are met, select the right vaccine code looking at type of vaccine(s) used and the age of the patient. Choose Appropriate Code Based on Vaccine and Patient Age When reporting an administration of tetanus vaccine, choose the appropriate code for the vaccine depending on the age of the patient that received the vaccine and on the type of vaccine used. Based on these criteria, you have ten choices to appropriately report the type of vaccine that was used on the patient: 90696 (Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated [DTaP-IPV], when administered to children 4 through 6 years of age, for 90698 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated [DTaP - Hib IPV]), for 90700 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine [DTaP], when administered to individuals younger than 7 years, for 90702 (Diphtheria and tetanus toxoids [DT]) adsorbed when administered to individuals younger than 7 years, for 90703 (Tetanus toxoid adsorbed, for 90714 (Tetanus and diphtheria toxoids [Td] adsorbed, preservative free, when administered to individuals 7 years or older, for 90715 (Tetanus, diphtheria toxoids and acellular pertussis vaccine [Tdap], when administered to individuals 7 years or older, for 90720 (Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine [DTP-Hib], for 90721 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine [DTaP-Hib], for 90723 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated [DtaP- HepB-IPV], for. Coding tip: If only tetanus toxoid was administered to the patient, you will not have to worry about the age of the patient as you will be reporting 90703. This code does not contain any age particulars in its descriptor and can be used for any patient irrespective of their age. Don t Forget to Additionally Report Administration Code While the above mentioned CPT code choices are used to choose the type of tetanus vaccine that was administered to the patient, you will also have to report an administration code. You will choose the appropriate code for the administration based, first, on the age of the patient. When administered in young patients, you will also have to check documentation to see if counseling about the vaccine was provided to the patient or the parents of the patient by a physician or other
qualified health care professional (e.g. nurse practitioner or physician assistant). Based on the age of the patient and whether or not physician/qualified health care professional counseling was provided, you have the following CPT code choices that you can use to report the administration of the tetanus vaccine: 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]). Reminder: You will report the add-on codes +90461 or +90472 only in cases where other vaccines (+90472) or vaccine components (+90461) were also provided to the patient during the same visit and not as primary codes when only tetanus vaccine was administered. Examine Coverage Criteria For Medicare Patients Medicare does not currently pay for the Tetanus vaccines under Part B in the absence of an illness or injury, since it is not one of the preventive vaccines statutorily covered under Part B. However, Medicare Part B does cover Tetanus or Tetanus Diptheria toxoids in the event of an injury, because, at that point, it is considered medically necessary for the treatment of an illness or injury. The Medicare Benefit policy manual (chapter 15, section 50.4.4.2) states, Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule. Note that Medicare Part D plans generally cover vaccines that Part B does not cover. If a Medicare patient has Part D coverage, he or she may be able to get the tetanus vaccine paid by his or her Part D plan, even in the absence of an illness or injury. Important: If your FP administers Tetanus or Td / DT vaccine to a Medicare patient in the absence of an injury, you may collect the money from the patient by having the patient sign an Advance Beneficiary Notice (ABN) before providing the service. But make sure to append modifier GA (Waiver of liability statement issued as required by payer policy, individual case) to the vaccine and its administration when the claim is submitted to Medicare, which indicates that the provider or supplier has provided an ABN to the patient. Medicare will deny such claims, and the explanation of benefits will note that the patient is responsible for payment. Use Appropriate Diagnosis Codes to Facilitate Coverage Your primary diagnosis should be one of the ICD-9 V codes indicating the need for prophylactic vaccination against bacterial diseases or combinations of diseases (e.g.,v03.7, Need for prophylactic vaccination and inoculation against bacterial diseases; tetanus toxoid alone orv06.5, Need for prophylactic vaccination and inoculation against combinations of diseases; Tetanus-diphtheria [Td] [Dt]). If the vaccination was prompted by an injury, you will also report an injury related ICD-9 code as the secondary diagnosis. For instance, when the injury was caused due to the patient stepping on a rusty nail, you might report 892.0 (Open wound
of foot except toe[s] alone; without mention of complication) and E920.8 (Accidents caused by cutting and piercing instruments or objects; other specified cutting and piercing instruments or objects). ICD-10: When ICD-10 codes come into effect after Oct.1, 2015, you will report Z23 (Encounter for immunization) in lieu of V03.7 and V06.5. - Published on 2019-01-01