Pediatric Annals

Coding and Payment for Immunizations

Richard H Tuck, MD, FAAP

Abstract

Pediatricians must be familiar with multiple requirements to optimize reimbursement for vaccine-related costs

Abstract

Pediatricians must be familiar with multiple requirements to optimize reimbursement for vaccine-related costs

With the number of recommended childhood vaccines reaching 20 and climbing, a critical aspect of the business of running a pediatrie practice is providing immunizations in a cost-effective manner. Childhood immunizations are best managed in the "medical home" of primary pediatrie care. However, it must be recognized that problems with reimbursement for immunizations are common. Providers cannot be expected to operate at a loss as a result.

This article provides current information on coding standards for childhood immunizations, medically necessary counseling practices, and payment issues common to pediatrie practice.

CURRENT IMMUNIZATION CODING

To optimize payment, decrease liability, and improve information flow, physicians must become knowledgeable about appropriate coding from Current Procedural Terminology (CPT)1 and International Classification of Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM).2 Proper coding for medical procedures is especially important in the world of immunizations, made more dramatic by ongoing changes in this challenging area of practice.

A practice's process for providing immunizations should include billing for and documenting the evaluation and management visit, the immunization administration, and the vaccine and toxoid products. Pediatricians and their practices should be familiar with and use the specific CPT codes for each of these services (Sidebar 1). These should then be Jinked to appropriate ICD-9-CM diagnosis codes, including the V20.2 for the well-child visit, the specific vaccine V codes, and any associated medical conditions (Sidebar 1). These code sets are updated and maintained regularly to stay current with and anticipate changing immunization recommendations.

CPT Immunization Administration Codes

The immunization administration codes include administrative staff services (eg, making appointment, preparing and handling of chart, billing for service); clinical staff services (eg, greeting patient, routine vital signs, vaccine history, presenting Vaccine Information Sheet [VIS], preparing and administering vaccine, observing for reactions, and chart documentation); medical supplies (eg, gloves, syringe, needle, alcohol swabs, bandages); and medical equipment (eg, examination table). Immunization administration codes do not include other evaluation and management services.

The CPTBasic Immunization Administration code set is described in Table 1 (see page 509). The CPT Pediatric-Specific Immunization Administration code set is shown in Table 2 (see page 509) and requires physician counseling for patients younger than 8. The elements required for physician counseling are listed in Sidebar 2 (see page 509).

Selecting the appropriate administration codes from these code sets requires literal interpretation of the CPT guidelines, with accurate supporting documentation. Requirements include route of administration and number (eg, first, each additional). This also includes meeting requirements for physician counseling and age as needed. Use of a screening questionnaire, such as that described by Veraas (see page 519), when reviewed and discussed with the parent, helps to meet the physician counseling requirement specified in these codes.

It should be noted that advanced practice nurses (APN) and physician assistants (PA), subject to state scope of practice, may use the pediatric-specific immunization administration codes requiring physician counseling. However, they cannot be used for a nurse providing the immunizations under direct phy- » sician supervision. Additionally, while they do require physician counseling, the pediatric-specific codes do not require that the physician perform the actual vaccine administration. This can still be performed by clinical staff.

Immunization administration codes can be used in a "mix and match" fashion when applied literally. However, associated immunization restrictions also apply, such as the restriction that two first-time administration codes cannot be used at the same visit (eg, 90471 and 90473, 90465 and 90467). It is generally acknowledged that the current immunization codes do not address the additional physician work involved in administering multiple-component vaccines. The AAP is working with the coding development process and guidelines to address this obstacle to optimal immunization practice.

Payment Based on Relative Value

The resource-based relative value scale as developed and maintained by the Center for Medicare and Medicaid Services now includes values for immunization administration, which, when multiplied by a conversion factor, results in a supportable charge for the services. Table 3 (see page 510) shows the relative value unit (RVU) multiplied by the 2006 Medicare conversion factor of $37.8975. These values currently are equal for both the basic and pediatric-specific administration code sets and provide a reasonable basis for immunization administration charges.

Table

TABLE 1.Basic Immunization Administration Codes

TABLE 1.

Basic Immunization Administration Codes

Table

TABLE 2.Pediatric-Specific Immunization Administration Codes

TABLE 2.

Pediatric-Specific Immunization Administration Codes

CODING FOR ASSOCIATED SERVICES

If a significant, separately identifiable evaluation and management (E/M) service (eg, office, preventive medicine, other outpatient) is provided, the appropriate E/M service code should be reported in addition to the vaccine/toxoid administration codes. Although not required in CPT guidelines, some payers may require a -25 modifier on the E/M code for payment of both the E/M and the vaccine administration services.

99211 Incident To Immunization Coding

The 99211 E/M code, the lowest level of established office visit evaluation and management service, can be used appropriately when it is provided by medical assistants and nurses as a necessary, separately identifiable evaluation and management service. The 99211 code does not require face-to-face physician contact. It is reportable under the physician's name and tax identification number, making it an "incident to" service, and requires the direct supervision of the physician (physician present in the office suite). Appropriate E/M documentation is required, signed by the medical assistant and countersigned by the physician. Unfortunately, it usually also requires a copay, subject to the patient's insurance plan design, which the physician is obligated to collect.

Table

TABLE 3.2006 Medicare Payment for Vaccine Administratiun CPT Codes

TABLE 3.

2006 Medicare Payment for Vaccine Administratiun CPT Codes

The 99211 code musí be used only for a medically necessary service and must be a significantly separate E/M service from the immunization administration. Documentation should include the date of service, reason for the visit, brief history of problems, examination elements (vital signs), brief assessment, and disposition. Additional support for the use of the 99211 code would be an appropriate link to a different ICDP-CM diagnostic code.

The AAP has conducted extensive research on the use of 99211 with nurse-administered immunizations and released a position paper on its use.3 The use of the 99211 EM code is supported by the American Medical Association.4'5 CPT also reaffirms the use of a reportable E/M service as significant and separate from the immunization administration itself. However, a recent statement by the Center for Medicare and Medicaid Services6 indicates that, when the nurse sees the patient and gives an injection, it is not correct to report an E/M service if the nurse's services are only related directly to the injection itself. Correct coding would allow for a separately identified immunization service to be billed with the 99211 code. However, private payers often follow Medicare guidelines, making this option difficult.

Physicians should question payers, including state Medicaid programs, when developing office policies on reporting nursing services (ie, 9921 1) with vaccine administration. Practices should report the code combination only when separately identified E/M services are provided and follow up on explanations of benefits received from payers to assure recognition and payment.

CASE EXAMPLE #1

A 6-month-old girl had a high fever diagnosed as a viral illness at her preventive medicine visit 2 weeks earlier. She now returns for her delayed 6-month vaccinations.

The nurse performs an interval history, documenting that the illness has resolved. Her temperature is measured, and the observation made that the infant is alert and playful. It is confirmed that there are no contraindications to the immunizations per CDC guidelines. The nurse reviews the VIS and fever treatment and obtains consent for immunizations. The scheduled diphtheria-tetanus-perrussis (DTaP), polio (IPV), and pneumococcal conjugate (PCV) vaccines are given. Complete documentation of the E/M components as well as vaccine documentation and administration is completed, signed by the nurse, and countersigned by the physician. Table 4 (see page 511) shows the appropriate reporting codes.

CPT Vaccine/Toxoid Product Codes

Each vaccine product has a separate and unique CPT code. The reimbursement for vaccines should cover not only administration but also the price of the vaccine product itself, including shipping and handling, excise taxes, and storage. A current complete list of vaccine and toxoid products is presided in the membersonly section of on the American Academy of Pediatrics (AAP) web site.7

ICD-9-CM Diagnostic Coding

Supporting links of CPT service and 1CD-9-CM diagnosis coding must be completed. Associated E/M codes should be linked to ICD-9-CM codes; this includes linking office visits to an ICD-9-CM diagnosis and preventive medicine visits to supporting V codes (V20.2 - routine infant or child health check).

There are vaccine/toxoid product ICD-9-CM (V) codes specific to almost all products used for immunization, as well as the CPT codes discussed. The codes are used to report the product only and are specific to the product, vaccination schedule, route of administration, dosage, and indicated age.

The coding system also develops codes in anticipation of Food and Drug Administration approval of new vaccines. New in CPT for 2006 is the symbol *, the "lightning bolt", indicating FDA approval is pending for the specific vaccine listed. For example:

(*) 90698 DTaP-Hib-IPV.

It should be noted that some payers may deny claims inappropriately when they link CPT codes to a "V" ICD-9-CM code. However, CFT and ICD-9-CM guidelines support the use of V codes when they are the most specific codes available to reflect the reason for the encounter. Pediatricians may need to pursue payment aggressively in these cases.

CASE EXAMPLE #2

A physician or an advanced practice nurse provides a preventive medicine visit to a 14-year-old patient, including faceto-face counseling for intranasal influenza vaccine and optional counseling and provision of tetanus/diphtheria toxoids/acellular pertussis vaccine (Tdap). Table 5 shows the appropriate reporting codes.

IMMUNIZATION GRAY AREAS

The addition of the 2005 pediatrie immunization administration code set has resulted in gray areas in immunization administration. Physician face-toface counseling applies only to the new pediatrie specific codes, 90465 through 90468. The question then arises as to what immunization codes should be used for the nurse-only immunization visit for a child who is younger than 8. The correct codes to use are 90471 through 90474, as there is no physician counseling in the interaction.

Another issue is the question of physician involvement in counseling for visits that include vaccine boosters. Again, it would be appropriate to bill 90465 through 90468 if there is face-to-face physician counseling. This typically occurs to some extent for updating past reactions, how they are managed, and the current status of the health of other family members. However, if no physician counseling is provided, the appropriate codes would again be 90471 through 90474.

Further, advanced practice nurses and PAs can report using codes 90465 through 90468 if they provide counseling. However, nurses who are not APNs cannot report 90465 through 90468 as "incident to" the physician. CPT is specific in requiring that a physician, advanced practice nurse, or PA must provide the face-to-face counseling to use these codes.

Table

TABLE 4.Coding for Case Example #1

TABLE 4.

Coding for Case Example #1

REIMBURSEMENT ISSUES

As vaccine costs have escalated through the years, so has the importance of adequate above-cost provider payment for the immunizations. This is central to the viability of pediatrie practices and their mission to furnish a complete medical home that provides access to care for patients, including immunizations. As new vaccines are developed and administration schedules updated, pediatricians find themselves caught in the middle, facing a risk of potential economic hardship as a result of providing new vaccine products.

Table

TABLE 5.Coding for Case Example #2

TABLE 5.

Coding for Case Example #2

This situation becomes particularly difficult when new vaccine products are released and there is a delay in the uptake and payment systems by payers for recommended immunizations. It is also a quagmire for pediatricians when the manufacturers increase the charges for their products without notice, making reimbursement difficult due to contract restrictions and a delay in adjusted payments. Vaccine product costs typically are related to the Average Wholesale Price or Average Sale Price, which is updated only quarterly, lagging behind timely vaccine price increases.8

Pediatricians also are faced with determining the patient's insurance status and coverage for vaccines, including newly released and recommended vaccines. If these vaccines are not a contracted covered benefit for the patient, balanced billing can be done with reasonable notice to the patient. A signed advance beneficiary notice form should be completed by a parent or guardian to support the understanding of their financial obligation.

Some pediatricians find themselves in the untenable position of furnishing vaccines at less than their cost. The AAP is actively involved in addressing these issues by working with pediatricians and payers on all the components necessary to maintain delivery of immunization services in the medical home. The AAP Private Payer Advocacy Committee position paper "The Business Case for Pricing New Vaccines" acknowledges that pediatricians are running a business that must run on sound business principles, including the approach to new vaccines.9

Vaccine-related expenses are defined, including the administration fee, as purchase price of the vaccine, personnel costs for ordering and inventory, storage costs, insurance to assure against loss, and estimated wastage/nonpayment. There is also the additional lost opportunity cost in maintaining a vaccine inventory. The bottom Une is a vaccine price that should stand on its own, and "be at least 17-28% above the vaccine purchase price," according to the AAP.9 This price needs to be negotiated aggressively and renegotiated with the consideration of the option of additional costs moved to the vaccine charge.

The Vaccines for Children Program for underinsured children also creates challenges and opportunities for pediatricians unique to each state's program. The vaccines are provided at no cost to pediatricians, and only the immunization administration is reimbursed, at state-determined rates. Providers who participate in the state's program must become knowledgeable about the vaccines covered, as well as the coding guidelines, which may not be consistent with the coding principles discussed in this article.

SUMMARY

To maximize reimbursement rates for services related to immunization delivery, pediatricians must develop a best-practice five step action plan for providing immunizations in practice. These include:

* Implementing optimal coding practices for immunization administration and vaccine products;

* Capturing the work of associated evaluation and management services with coding;

* Supporting CPT coding with appropriate ICD-9-CM diagnostic coding links;

* Incorporating an immunization coding menu, including CPT and ICD-9-CM codes discussed in this article, into the standard practice encounter form; and

* Aggressively contracting with payers for adequate, flexible payment for immunization services.

With knowledge of immunization CPT and ICD-9-CM coding, as well as coding for association E/M visits, the pediatrican is well prepared to deliver immunizations in the medical home. However, this must be done with a complete understanding of the complex payment issues discussed in this article.

REFERENCES

1. American Medical Association. 2006 CPT: Current Procedural Terminology. Chicago, IL: American Medical Association; 2005

2. American Medical Association. ICD-9-CM 2006: International Classfication of Diseases. Chicago, IL: American Medical Association; 2005.

3. When Is It Appropriate to Report 99211 During Immunization Administraction? January 17, 2006. American Academy of Pediatrics Committee on Coding and Nomenclature. Available at: http://www.cispimrnunize.org/ pro/AAPPositionPaper9921 1 .pdf . Accessed May 31, 2006.

4. Immunization administration at time of E/M service. CPT Assistant. 1999;9(10):9.

5. New vaccine administration procedure codes. CPT Assistant. 2005;15(4):1-5.

6. National Correct Coding Initiatives Edits - Physicians. US Department of Health and Human Services, Centers for Medicare and Medicaio Services. 2006. Available al: http://www.cms.hhs.gov/NationalCorrectCodlnitEd/NCCIEP/listasp. Accessed June 20, 2006.

7. Commonly Administered Pediatrìe Vaccines/ Toxoids and Immune Globulins. 2006. American Academy of Pediatrics. Available at: http://www.aap.org/moc/reimburse/VaccineCodingTable.doc. Accessed May 31, 2006.

8. Red Book: Pharmacy's Fundamental Reference. Stamford, CT: Thomson Healthcare; 2006.

9. The Business Case for Pricing New Vaccines. American Academy of Pediatrics. Available at: http://www.aap.org/moc/reimburse/BusinessCase.pdf. Accessed May 31, 2006.

TABLE 1.

Basic Immunization Administration Codes

TABLE 2.

Pediatric-Specific Immunization Administration Codes

TABLE 3.

2006 Medicare Payment for Vaccine Administratiun CPT Codes

TABLE 4.

Coding for Case Example #1

TABLE 5.

Coding for Case Example #2

10.3928/0090-4481-20060701-07

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