On January 5, the American Academy of Pediatrics (AAP) posted on its website the eight-page document Comprehensive Overview: Immunization Administration 2005. The document describes the eight immunization administration CPT codes [current procedural terminology codes] now available; included in the eight codes are four new codes. It also presents a series of questions and answers that explain how to use the codes. The document is reprinted below in its entirety, with the exception of one table for which a link is given.
There have been significant changes to immunization administration in terms of both procedure codes and their valuation, which have brought about a myriad of questions and concerns. What follows is an overview of the changes along with answers to frequently asked questions (FAQs) about the new codes and their valuation for 2005.
Codes 90465-90468 are listed in the CPT manual just prior to the 90471-90474 immunization administration codes, in the beginning of the Medicine Section.
HOW ARE THE NEW CPT CODES REPORTED?
Q. Are the new codes reported in addition to the existing codes?
A. No. The new codes, like the old codes, are immunization administration codes--they are not add-on "counseling" codes. Therefore, the reporting of a new code plus an old code for a single administration would constitute double reporting of the service.
Q. How do you determine when to report the new codes and when to report the existing codes?
A. The new codes have two requirements: (1) the patient must be under 8 years of age and (2) the physician (not the clinical staff) must perform face-to-face vaccine counseling associated with the administration. If both of these requirements are not met, report a code from the 90471-90474 code family instead.
Q. Can you report codes from both code families (90465-90468 and 90471-90474) during a single patient encounter?
A. While this may not be a common scenario, codes from both families can be reported during a single patient encounter. This might happen if the patient is receiving a vaccine that is new to them and a "repeat" vaccine (e.g., the third hepatitis B vaccine in the series). The physician may provide vaccine counseling on the new vaccine (and report a code from the 90465-90468 code family) but not on the repeat vaccine (and report a code from the 90471-90474 code family).
Q. I noticed that CPT now contains restrictions regarding which immunization administration codes can be reported together (e.g., "Use 90466 in conjunction with 90465 or 90467") and which cannot (e.g., "Do not report 90473 in conjunction with 90471"). Can you clarify what these mean?
A. The overarching rule behind these restrictions can be boiled down to one concept: you cannot report two "first" administrations during a single patient encounter. Therefore, if you administer one injectable vaccine and one intranasal vaccine during a single patient encounter, you would report 90465 (or 90471) for the first (injectable) vaccine and 90468 (or 90474) for the second (intranasal) vaccine. CPT indicates that in such a situation, you could not report 90465 plus 90467 (nor could you report 90471 plus 90473) since both codes are for the first administration given during the patient encounter. The resources expended (and, therefore, the relative value units assigned) to the "first" administration codes are slightly higher than the resources expended (and the relative value units assigned) for the "each additional" administration codes. Therefore, reporting more than one "first" administration code during a single patient encounter would constitute double dipping.
Q. How does CPT define a "first" administration? Can the "first" administration codes only be used once during the patient's entire tenure in our practice? Or are they reserved for only the "first" administration in a particular vaccine series (e.g., reserved for only the first DTaP shot in the series)?
A. CPT defines the "first" administration as the first vaccine administered to a patient during a single patient encounter. Therefore, the "first" administration codes can be reported throughout the patient's entire tenure in your practice. Furthermore, the "first" administration codes are not reserved only for use with the first shot in a vaccine series--a "first" administration code can be used for the first DTaP shot as well as for the second, third, or fourth DTaP shots.
Q. Does it matter which vaccine is coded as the "first" administration? For example, if I administer both an injectable vaccine and an intranasal vaccine during a single patient encounter, do I have to report 90465 plus 90468 (or 90471 plus 90474)? Or could I alternatively report 90467 plus 90466 (or 90473 plus 90472)?
A. You can report either combination. However, since the oral/intranasal immunization codes (90467, 90468, 90473, and 90474) are presently unvalued on the Medicare Resource-Based Relative Value Scale (RBRVS), payors that utilize RBRVS in setting their fee schedules are likely to reimburse poorly for these codes. Additionally, since the "first" administration code is typically recognized by most payors (and some payors have trouble in fully understanding how the "each additional" administration codes work), it may serve you better to report the injectable administration as the "first" administration, at least for the time being. The Academy is presently working toward getting values published for the oral/intranasal immunization administration codes.
Q. Do the new pediatric immunization administration codes require that the physician perform the actual vaccine administration?
A. No. The new codes do not require that the physician do the actual vaccine administration. The clinical staff may perform the actual vaccine administration. The new codes require that the physician perform face-to-face vaccine counseling in conjunction with the administration.
Q. Our clinic has facility-employed nurses who perform our vaccine administrations. The nurses report their services under the facility's tax ID number using the immunization administration codes (90471-90474) while the physicians capture their vaccine counseling in an E/M [evaluation and management] code reported under their separate tax ID numbers. How can the new pediatric immunization administration codes (90465-90468) be reported in our situation?
A. Since your reporting of immunization administration essentially splits the actual administration (as performed by the facility-employed nurses) from the physician counseling (as performed by the physicians), the new pediatric immunization administration codes would not be appropriate for your situation.
Your physicians should continue to report vaccine counseling by including it in the E/M code. It should be noted that if greater than 50% of the total time spent in providing an E/M visit is spent counseling or coordinating care, then time can be used as the key factor in selecting the appropriate level E/M code. Therefore, in certain situations, it would be possible for the physician to report a higher level E/M code when incorporating significant vaccine counseling into the visit.
Your nurses should continue to report their services using the 90471-90474 immunization administration codes.
The immunization administration codes (90471-90474) and the pediatric immunization administration codes (90465-90468) are valued identically on the Medicare Resource-Based Relative Value Scale (RBRVS) for 2005. This means that the fact that you cannot report the pediatric immunization administration codes will not have a negative impact on your bottom line.
The CPT descriptors for codes 90465-90468 specifically require "physician (vaccine) counseling of the patient/family." In addition to the charting of the vaccine itself (product, lot number, site and method, VIS date, etc., which are all usually recorded on the immunization history sheet), the physician should document that he/she personally performed the face-to-face vaccine counseling for the listed vaccines.
The preventive medicine visit and any other services provided during the encounter would be reported separately.
Code 90468 is reported for the additional immunization administration rather than code 90467. This is due to the fact that you cannot report more than one "first" administration code during a single patient encounter.
Evaluation and management (E/M) or any other services provided during the encounter would be reported separately.
While the physician does conduct the vaccine counseling, the patient is over 8 years of age. Therefore, immunization administration codes from the 90471-90474 code family would be reported.
WHY WERE THE NEW CPT CODES DEVELOPED?
The Academy developed the new codes in an effort to get the Centers for Medicare and Medicaid Services (CMS) to recognize the physician work involved in administering vaccines in the pediatric population. This "recognition" could have been achieved had CMS published physician work relative value units (RVUs) for the existing immunization administration codes (90471-90474) on the Medicare Resource-Based Relative Value Scale (RBRVS). Over the past six years, however, CMS repeatedly commented that it did not intend to publish physician work RVUs for codes 90471-90474. Rather, CMS indicated that if pediatric-specific immunization administration CPT codes could be developed, it would reconsider the Academy's request to have physician work RVUs published on the Medicare RBRVS. Therefore, after some compromise with CMS as to the exact verbiage and age cut-off for the new codes, the Academy went to the CPT Editorial Panel with a proposal for new pediatric immunization administration codes. The Panel approved the Academy's request in November 2003, making the codes effective for the CPT 2005 cycle.
Q. Why do the 90465, 90466, 90467, and 90468 codes have the same RVUs as the 90471, 90472, 90473, and 90474 codes? I thought that they would be valued higher since they are age-restricted and specifically require "physician counseling."
A. CMS's valuation of codes 90471-2 equal to that of codes 90465-6 was a (pleasant) surprise. The Academy worked for six years to get physician work RVUs published on the Medicare physician fee schedule for immunization administration. During that period of time, CMS repeatedly commented that it did not intend to publish physician work RVUs for codes 90471-90474. Rather, CMS indicated that if pediatric-specific immunization administration CPT codes could be developed, it would reconsider the Academy's request to have physician work RVUs published on the Medicare RBRVS. Therefore, once we had the pediatric-specific CPT codes (90465-90468) in place, we assumed that they would be valued higher (since they would include physician work RVUs) than the existing immunization administration codes.
However, at the same time that this was occurring, Congress passed the Medicare Modernization Act of 2003 (MMA). One outcome of MMA was the revaluation of the drug infusion and therapeutic injection codes, adding physician work RVUs and significantly increasing the practice expense RVUs to counteract the substantial decrease in reimbursement for oncology drugs. In an effort to allow equivalent valuation among similar services, CMS decided to increase the practice expense RVUs and add physician work RVUs for the immunization administration codes, as well, including both the existing and new codes in the revaluation.
Q. Doesn't the fact that they are identically valued to the existing codes make the new immunization codes essentially obsolete?
A. While the fact that there is no differential between the RVUs for codes 90471-4 and the RVUs for codes 90465-8 is disappointing, the total RVUs for all the immunization administration codes are more than double what they were last year. For example, the 2004 RVUs for 90471 were 0.22. This year, they are 0.49.
Furthermore, it's too soon to tell, but private payors may reimburse higher for the new codes since their code descriptors contain more requirements than the code descriptors for 90471-4.
Finally, the fact that there are now pediatric-specific codes for immunization administration in the CPT nomenclature establishes an important precedent. Pediatric immunization administration is now differentiated as a unique service, separate from the model of immunization administration provided in the adult population.
Q. What about combination vaccines? The new codes still don't address the extra physician work involved in administering multiple component vaccines.
A. Based on the success that we have had so far, the Academy is starting work on revising the immunization administration codes to better account for the increased physician work and reduced practice expense associated with combination vaccines. Those code revisions, if approved by the CPT Editorial Panel, would not become effective until 2007 at the earliest.
Q. Why aren't the oral/intranasal immunization codes valued?
The American Medical Association has reported that 74% of non-Medicare payors utilize Medicare RBRVS in determining their fee schedules (Medicare RBRVS: The Physicians' Guide 2004, Chapter 13). CMS has previously acknowledged this phenomenon through its publishing of RVUs for the Preventive Medicine Services codes (99381-99397) even though such services are not covered under the Medicare program. AAP's strong commitment to and involvement in the RUC process should be testament to the enormous influence that the Medicare physician fee schedule has on the majority of non-Medicare payors, including state Medicaid agencies. It should also be noted that the immunization administration codes provide the entire reimbursement support for the practice expense related to vaccines delivered to children through our nation's Vaccines For Children (VFC) Program. Therefore, due to Medicare RBRVS's far-reaching influence, CMS has a responsibility to publish RVUs for codes even when such services may not be covered under the Medicare program.
Codes 90467, 90468, 90473, and 90474 have all been through the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), where both physician work RVUs and direct practice expense inputs have been approved and recommended for inclusion in RBRVS on several occasions. The fact that the RUC has approved RVUs for these codes lends exceptional credence and validity to the recommendations.
Due to the current national public health emergency created by the shortage of the injectable influenza vaccine, use of a live attenuated influenza vaccine administered intranasally is critical to meeting emergent needs. This vaccine has recently been added to the list of vaccines provided to children through the VFC program. Failure to publish relative values for oral/intranasal immunization administration creates a substantial barrier to meeting the medical needs of our country, particularly the needs of those people most at risk.
In addition to the current use of one intranasal vaccine, an oral vaccine for infants that prevents serious infection from rotavirus gastroenteritis will likely be licensed and receive a universal recommendation for use in all infants before the next RBRVS final rule is published. It is essential that CMS publish the RUC-recommended RVUs for the oral/intranasal immunization administration codes in order to support its use.
For questions, please contact Linda Walsh at lwalsh@aap.org or (800) 433-9016 Ext. 7931.