Q: Do you have information on the 2017-2018 influenza vaccine codes?
A: The American Medical Association (AMA) recently published a list of new and revised vaccine codes on their website (https://www.ama-assn.org/sites/default/files/media-browser/public/cpt/vaccine-long-desc-july-2017.pdf). These codes will be published in the 2018 Current Procedural Terminology (CPT) manual. The two new influenza vaccines on the list are:

  • 90682, “Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use”
  • 90756, “Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage, for intramuscular use”

CPT code 90682 was made effective January 1, 2017, and CPT code 90756 will be effective as of January 1, 2018. The latter, however, comes with some special billing instructions since the vaccine is currently available for use. The Centers for Medicare and Medicaid Services (CMS) recently revised MLN Matters Number: MM10196 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10196.pdf) with distinct instructions on how to bill when ccIIV4 is given before and when it is given after January 1, 2018.

For vaccinations administered between August 1, 2017 and December 31, 2017, Medicare Advantage Carriers (MACs) will use Healthcare Common Procedure Coding System (HCPCS) Level II code Q2039, “Influenza virus vaccine, not otherwise specified.” (Check with your commercial payors to see if they expect to see this HCPCS code on claims or if they prefer CPT code 90749, “Unlisted vaccine/toxoid.”)

CPT code 90756 is not retroactive to August 1, 2017, and CMS states that claims using CPT code 90756 billed after January 1, 2018 for dates of service between August 1, 2017, and December 31, 2017, will be rejected or returned as unprocessable. Likewise, claims billed with HCPCS code Q2039 for the vaccine after December 31, 2017, will be rejected or returned as unprocessable.

CMS has published its payment allowance for the 2017-2018 flu season, also denoting the billing instructions for CPT code 90756 in the 2017 flu season. You can view the rates on the CMS website https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html.

Remember to bill the correct vaccine administration code(s) along with any vaccine(s) given. When billing Medicare, you will use the following HCPCS codes for influenza, pneumococcal, and hepatitis B, respectively:

  • G0008, “Administration of influenza virus vaccine”
  • G0009, “Administration of pneumococcal vaccine”
  • G0010, “Administration of hepatitis B vaccine”

CPT offers vaccine administration codes based on whether there is only one or multiple vaccines administered, the age of the patient, the number of components in the vaccine, and if face-to-face counseling was provided. When billing your commercial payers, you have the following administration codes to choose from:

  • 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)”
    • Use 90460 for each vaccine administered. For vaccines with multiple components (combination vaccines), report 90460 in conjunction with 90461 for each additional component in a given vaccine.
  • 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)”
  • Use 90472 in conjunction with 90460, 90471, and 90473.
  • 90473, “Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)”
  • 90474, “…each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)”
    • Use 90474 in conjunction with 90460, 90471, and 90473.

The diagnosis code to use when billing vaccinations is Z23, “Encounter for immunization.”
Q: Do you have any details on how the Centers for Medicare and Medicaid Services (CMS) is planning to update the Evaluation and Management (E/M) coding guidelines and when that will happen?
A: CMS announced this past July that they were ready to move forward with reforming E/M documentation guidelines in the 2018 proposed Medicare physician fee schedule released July 13, 2017, (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-P.html). The idea was to better align E/M coding and documentation with the current practice of medicine. CMS anticipates the most significant changes to be in the history and physical exam components of the E/M service, with the possibility of removing the documentation requirements at all levels, stating that medical decision-making (MDM) and time are the more significant factors contributing to the level of E/M service provided. According to Part B News (July 13, 2017), “CMS may overhaul E/M coding; history (and exam) may be history.”

CMS states that “as long as a history and physical exam are documented and generally consistent with complexity of MDM, there may no longer be a need for us to maintain such detailed specifications for what must be performed and documented for the history and physical exam.”

If CMS moves forward with the proposal, it is expected to take many years and coordination with multiple entities and professionals of the medical and healthcare industry.

New Flu Vaccine Codes—and an Update on Proposed Changes to the E/M Guidelines
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