American Academy of Family Physicians
Wednesday Aug 27, 2014

Medicare plans new coding modifiers for 2015

The Centers for Medicare & Medicaid Services (CMS) recently announced that it is creating four new Healthcare Common Procedure Coding System (HCPCS) modifiers that will further refine the popular -59 modifier.

Adding a modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Family physicians and others often use it to override edits found in Medicare’s National Correct Coding Initiative (NCCI). In fact, according to CMS, -59 is the most widely used modifier in the HCPCS.

That popularity is partly because, as currently defined, the -59 modifier can be used in a wide variety of circumstances, such as identifying different encounters, different anatomic sites, or distinct services. But physicians aren't always clear on why they're using the modifier, and, from CMS’s perspective, that usage is not always correct. CMS believes it can reduce the incorrect use of modifier -59 – and the subsequent Medicare overpayments – with a combination of more precise coding options, increased education, and selective editing.

As noted in the latest Medicare Learning Network Matters article, CMS on Jan. 1, 2015, will establish four new HCPCS modifiers to define specific subsets of the -59 modifier. They are referred to collectively as -X{EPSU} modifiers:

•    XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter,
•    XS - Separate Structure, a service that is distinct because it was performed on a separate organ/structure,
•    XP - Separate Practitioner, a service that is distinct because it was performed by a different practitioner, and
•    XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

For the time being, CMS will continue to accept the -59 modifier. But don't expect that to last indefinitely as the agency notes that, under CPT, physicians should not use the -59 modifier when a more descriptive modifier is available. That means CMS may decide to require a more specific - X{EPSU} modifier for billing certain codes it believes are more likely to generate billing errors. For example, CMS may designate a particular NCCI code pair as payable only with the –XE (Separate Encounter) modifier and not the -59 or other -X{EPSU} modifiers. So be prepared to be more selective in your use of modifiers with Medicare in the near future.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Jun 17, 2014

Potential pitfall in Medicare billing: office visits billed for hospital inpatients

This week, we conclude our series (see previous posts here, here, and here) on how to avoid common Medicare billing errors by focusing on billing the wrong kind of evaluation and management (E/M) code for patient visits provided in a hospital inpatient setting.

If you are rendering an E/M service to a patient in an inpatient hospital setting, then you should typically report that service with a CPT code from one of the following families:

•    99221-99223 – Initial hospital care
•    99231-99233 – Subsequent hospital care
•    99238-99239 – Hospital discharge services

Unfortunately, Medicare contractors are finding that physicians sometimes use a CPT code from the 99201-99215 family (Office or other outpatient services) for encounters with hospital inpatients. The example given is an 80-year-old female admitted to a hospital for an inpatient level of care on Oct. 17 and discharged on Oct. 20. A physician billed CPT code 99205 (Office or other outpatient visit for the evaluation and management of a new patient) for the date of service of Oct. 18. Because Oct. 18 was during the inpatient hospital stay and the patient was not on a leave-of-absence from the hospital on that date, the contractor deemed the service an overpayment.

So, if you are billing E/M services for a patient in an inpatient hospital setting, then you need to use hospital visit codes to report those services and avoid office/outpatient visit codes for dates of service corresponding to the patient’s hospital stay.

For additional information, check out Medicare’s Evaluation and Management Services Guide and sections,, and 30.6.10 of chapter 12 of the Medicare Claims Processing Manual.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday May 30, 2014

Potential pitfall in Medicare billing: psychotherapy in conjunction with an evaluation and management service

Four times a year, the Centers for Medicare & Medicaid Services (CMS) publishes its Medicare Quarterly Provider Compliance Newsletter, which seeks to help physicians avoid common Medicare billing errors. The latest issue highlights at least four errors that may be relevant to family physicians. This week, we’ll cover one related to psychotherapy provided in conjunction with an evaluation and management (E/M) service.

Family physicians are often the first point of contact for patients with mental health issues and sometimes provide psychotherapy to such patients in addition to an E/M service at the same encounter. Since January 2013, these services provided by the same provider on the same day are separately reportable and payable as long as they are significant, separately identifiable, and billed using the correct codes. In this situation, designated add-on codes are used to report psychotherapeutic services performed in addition to E/M codes.

Those CPT codes are:

•    +90833: Psychotherapy, 30 minutes with patient and/ or family member when performed with an E/M service
•    +90836: Psychotherapy, 45 minutes with patient and/ or family member when performed with an E/M service
•    +90838: Psychotherapy, 60 minutes with patient and/or family member when performed with an E/M service

CPT provides flexibility by identifying time ranges that may be associated with each of the timed codes:

•    90833: 16 to 37 minutes
•    90836: 38 to 52 minutes
•    90838: 53 minutes or longer

Psychotherapy sessions lasting less than 16 minutes are not separately reportable.

Documentation is crucial here. Time spent for the E/M service must be recorded separately from the time spent providing psychotherapy, and time spent providing psychotherapy cannot be used to meet criteria for the E/M service. Physicians can't enter one time period that includes both the E/M service and the psychotherapy.

CMS identified this blending of time periods as a common billing error in its quarterly newsletter. For example, a physician billed for a level 3 E/M service (99213) and 45 minutes of psychotherapy (90836). However, an authenticated printed visit note from the physician's electronic health record indicated total face-to-face time with the patient of 45 minutes and did not separately indicate the time spent providing psychotherapy services. The Medicare contractor, after an unsuccessful request for additional information, counted the claim as an overpayment due to insufficient documentation and recouped the payment from the physician.

Next week:  pitfalls associated with preventive services

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Feb 11, 2014

Medicare turns deaf ear to CPT changes on cerumen removal

Medicare payment policy doesn't always match the American Medical Association's Current Procedural Terminology (CPT).

The Centers for Medicare & Medicaid Services (CMS) provided another example of that recently in the final rule on the 2014 Medicare physician fee schedule.

For 2014, CPT revised its description of code 69210 to read, “Removal impacted cerumen requiring instrumentation, unilateral.” Previously, the code description read, “Removal impacted cerumen (separate procedure), 1 or both ears.” To account for situations in which the procedure is provided on both ears at the same encounter, CPT 2014 states, “For bilateral procedure, report 69210 with modifier 50.”

Unfortunately, CMS sees things differently. In the new 2014 fee schedule, CMS stated its opinion that the procedure will typically be done on both ears at the same encounter, because “the physiologic processes that create cerumen impaction likely would affect both ears.” CMS did not provide any evidence or citations to support this opinion.

CMS went on to say, “Given this, we will continue to allow only one unit of CPT 69210 to be billed when furnished bilaterally.” Consequently, CMS elected to maintain the 2013 work value of 0.61 for CPT code 69210 when the service is furnished.

The bottom line is that Medicare will pay you the same amount for 69210 whether you do one ear or two, even though the CPT descriptor now says it is for one ear only.

If only CMS could hear how ridiculous that sounds.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday Sep 30, 2013

Medicare updates influenza vaccine payment allowances

Fall is typically the season for administering influenza vaccine. Accordingly, the Centers for Medicare & Medicaid Services (CMS) recently published its annual update of influenza vaccine payment allowances.

The allowances printed in the update are for dates of services beginning Aug. 1, 2013, and ending July 31, 2014. Medicare administrative contractors have until Oct. 25, 2013, to implement the new payment allowances in their claims processing systems. The payment allowances apply when Medicare payment is based on 95 percent of the average wholesale price, except when furnished in a hospital outpatient department, a Rural Health Clinic, or a Federally Qualified Health Center for which payment is based on reasonable cost.

The update covers a variety of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes used to report influenza vaccine. These include some CPT codes that are new for 2014 and at least one, 90687 (Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use), for which Food and Drug Administration approval is still pending. You can find a list of the new CPT vaccine codes on the American Medical Association’s web site. As the information becomes available, CMS will post payment limits for influenza vaccines that are approved after the update’s release date, including CPT codes 90687 and 90688 (Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use), on the CMS Seasonal Influenza Vaccines Pricing webpage.

When billing for an influenza vaccine administered to a Medicare patient, don’t forget to also report the HCPCS administration code, G0008 (Administration of influenza virus vaccine).

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Jul 16, 2013

UnitedHealthcare jumping on vaccination bundling bandwagon

One of the nation's largest insurers is piggybacking on new restrictions that complicate physicians getting paid for performing vaccinations.

UnitedHealthcare (UHC) announced in its July 2013 Network Bulletin that it will align with Correct Coding Initiative (CCI) edits that went into effect Jan. 1, 2013. These changes, detailed in a February blog, affect evaluation and management (E/M) services and immunization administration codes.

UHC said that beginning in the third quarter of 2013 it will deny Current Procedural Terminology (CPT) codes 99201-99380 and 99401-99499 when reported on the same date of service as an immunization administration service (CPT codes 90460-90461 and 90471-90474). However, if the E/M code is reported with modifier 25, indicating it is a significant and separately identifiable service provided on the same day, UHC will pay for both codes. On the plus side, this policy change will not apply to preventive medicine E/M services (CPT codes 99381-99397 and Healthcare Common Procedure Coding System code G0402), which is often the type of E/M service during which vaccines are administered. 

No word yet on what other payers may also be following suit, but it’s a safe bet that UHC is not alone and will not be the last.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Feb 12, 2013

Decoding the new transitional care management rules

Ever since their introduction at the beginning of the year, the new transitional care management (TCM) codes have caused confusion.

The Getting Paid blog described the new codes when they were first announced last fall. But the questions have continued, and the codes are getting additional attention after the CPT Editorial Panel clarified in January that transitional care management involving new patients, and not just ones that a physician has seen within the previous 12 months, could be billed using the TCM codes.

Here are some of the more common questions:

Q. When should I bill for TCM?
A. You should submit your bill on the 30th day after discharge. TCM covers 30 days of management services with one evaluation service bundled into the code. The date of service on the claim would be the 30th day after the discharge.

Q. What happens if the patient is re-admitted before the 30 days are up?
A. The face-to-face visit would become the appropriate level evaluation and management code for the service that was rendered. You would restart your 30 days of service on the TCM once the patient was discharged.

Q. Does a discharge visit count as the post discharge contact?
A. No, a discharge visit does not count. The initial contact must be made after the patient leaves the hospital. This is to make sure that the patient has the support necessary until they have their face-to-face visit. The initial contact can be phone, e-mail, text, or face-to-face. It can involve the patient and/or the patient's caregiver.

Q. If the patient needs an unrelated evaluation and management (E/M) visit during the 30 days can I bill for this?
A. Yes, although there are some restrictions on what you can bill, such as anticoagulation management and home health care certification.

We’ve yet to hear how these codes are getting paid since the earliest billing date would have been Jan. 30, 2013. We are also waiting on the Centers for Medicare & Medicaid Services (CMS) to release guidelines on the codes, which we expect to receive by the end of February.

AAFP has created a form to help you document the requirements of TCM visits and made available for download a list of frequently asked questions. TCM was also discussed as part of an AAFP/TransforMED webinar, “What’s new in Medicare and Medicaid payment in 2013,” which is archived on TransforMED's Delta Exchange site and accessible to AAFP members upon login.  

–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians

Friday Nov 02, 2012

'Tis the season...influenza season, that is

The Centers for Medicare & Medicaid Services (CMS) released its annual update to influenza vaccine payments in early October, effective for dates of service on or after Aug. 1, 2012. Here’s an overview of what your Medicare contractor should be paying you.

CMS has payment allowances for several CPT and HCPCS codes for seasonal influenza virus vaccines. These allowances are typically based on 95 percent of the average wholesale price. However, when physicians furnish the vaccine in a hospital outpatient department, rural health clinic, or federally qualified health center, payment is based on reasonable cost and other allowances may apply.

The following table shows the payment allowances (based on 95 percent of the average wholesale price) for the most common codes:



Payment allowance


Influenza virus vaccine, split virus, preservative free, when administered to children 6 to 35 months of age, for intramuscular use



Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use



Influenza virus vaccine, split virus, when administered to children 6 to 35 months of age, for intramuscular use



Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular (Afluria)



Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)



Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)



Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)


Note that CMS has permitted payment allowances for some influenza vaccines to be set by the local claims processing contractor. Specifically, local contractors set the payment amounts for Q2034, Influenza virus vaccine, split virus, for intramuscular use (Agriflu), and Q2039, Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified).

Medicare payment for some other influenza vaccine codes is available only after the local claims processing contractor determines that the vaccine in question is medically reasonable and necessary for the beneficiary. These include:

•    90654 – Influenza virus vaccine, split virus, preservative-free, for intradermal use (Fluzone ID); Part B allowance of $18.981,
•    90660 – Influenza virus vaccine, live, for intranasal use (FluMist); Part B allowance of $23.456,
•    90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Fluzone High-Dose); Part B allowance of $30.923.

The additional scrutiny that Medicare is giving these codes is probably due in part to their costs compared with the traditional injectable influenza vaccine. Beyond that, code 90654 is a new code reflecting a new route of administration (i.e., intradermal), and the “enhanced immunogenicity” represented by code 90662 is probably not universally needed, leading Medicare to make sure that those who receive it do so appropriately. Finally, an article published by the Medicare contractor in Florida suggests that 90660 is only indicated for healthy individuals between 2 to 49 years of age, again leading Medicare to ensure that those who receive it do so appropriately.

In closing, it is worth pointing out that the allowances above are effective with dates of service on or after Aug. 1, 2012; however, Medicare contractors have until Dec. 28, 2012, to implement these allowances, so it is possible that some of your influenza vaccine claims may not be paid at the correct rate in the interim. Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors will adjust claims brought to their attention, so if you submitted a claim that is not paid at the correct allowance, you need to bring that claim to the contractor’s attention for adjustment.

For more information, check out the MLN Matters article (MM8047) "Influenza Vaccine Payment Allowances: Annual Update for 2012-2013 Season.”

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Sep 18, 2012

Putting E/M services on the RAC

In July, I posted about a report from the U.S. Department of Health & Human Services Office of the Inspector General (OIG) which found that from 2001 to 2010, physicians increased their billing of higher level evaluation and management (E/M) codes in all types of E/M services. In that post, I encouraged you to make sure that your documentation supports the level of E/M services that you are billing. With the OIG paying attention, the Centers for Medicare & Medicaid Services (CMS) were likely to follow suit, and you needed to be prepared.

Well, it appears that CMS was paying attention, or at least its recovery audit contractors (RACs) were. This week, CMS alerted the American Medical Association (AMA) that it has approved the Medicare Region C RAC. The contractor for Region C,  Connolly, is to begin conducting audits of coding for E/M services in physician offices, specifically CPT code 99215. According to the AMA, in the next several weeks Connolly will begin a complex medical review of code 99215 and will be permitted to extrapolate their findings based on a statistical sample of such claims. Connolly is the Medicare fee-for-service RAC contractor who conducts RAC audits in the following states:

  • Ala.
  • Ark.
  • Colo.
  • Fla.
  • Ga.
  • La.
  • Miss.
  • N.M.
  • N.C.
  • Okla.
  • S.C.
  • Tenn.
  • Texas
  • Va.
  • W.Va.
  • Puerto Rico
  • U.S. Virgin Islands

However, it has not yet been announced if all or only a subset of these states and territories will be under review. As of this writing, Connolly has not posted this information and other details of the review on its website. These reviews are expected to begin imminently in Region C and, according to CMS, are likely to be approved in other Medicare regions in the near future. 

The American Academy of Family Physicians, the AMA, and 100 other state and specialty societies sent a letter to CMS in March 2009 strongly opposing RAC audits of E/M services. However, the OIG report apparently encouraged CMS, through its RAC auditors to do otherwise.

So, what's a family physician to do? I would argue that the advice given in my July post still applies:  make sure that your documentation supports the level of E/M services that you are billing to Medicare. If you are subjected to a RAC audit, take some solace in the fact that, according to CMS' FY 2010 Recovery Auditor Report to Congress, 46 percent of the Medicare RAC determinations that were appealed were decided in the provider's favor. That means you have almost a 50/50 chance of prevailing in the long run. Of course, as John Maynard Keynes once observed, "In the long run, we are all dead." Hopefully, the prospects for physicians in this case are a bit more optimistic.

Tuesday Mar 29, 2011

The old "new patient" conundrum

In its most recent Medicare Quarterly Provider Compliance Newsletter (PDF download) the Centers for Medicare and Medicaid Services (CMS) highlighted an issue that apparently continues to be a problem for some physicians. Namely, when is a patient "new" for purposes of billing evaluation and management (E/M) services?

CMS defines a "new" patient in Chapter 12 Section 30.6.7 (PDF download) of the Medicare Claims Processing Manual as "a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years." This is essentially the same definition as in Current Procedural Terminology (CPT), which states, "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." CPT defines "professional services" as "those face-to-face services rendered by a physician and reported by a specific CPT code(s)." 

A simple way to determine if a patient is new is to ask yourself this question: "Have I (or another physician of my specialty within our group practice) provided a face-to-face service to this patient within the past 3 years?"  If the answer is no, then the patient is new to you for purposes of coding and billing the E/M service that you are providing to him or her.  If the answer is yes, then you must consider the patient established. Determination of whether the patient is new or established should not be made solely on whether the chart presented was new. Coding or charge entry staff should search for past billing records using the patient's social security number and date of birth, and if a billing record is found, contact the appropriate staff to compare the charts and determine if the patient is established. 

While some of your patients may be new, this issue is not, and apparently, it continues to sufficiently confuse some physicians that CMS felt it necessary to remind folks about the definitions involved. CMS issues the Medicare Quarterly Provider Compliance Newsletter to help physicians and their billing staffs understand the claims submission problems found by Medicare contractors and how to avoid certain billing errors and other improper activities when dealing with the Medicare. In light of that, you may want to check your own understanding of the new patient issue and related coding and billing practices, lest this become a compliance issue in your practice. 

Wednesday Mar 09, 2011

Drug screening codes have changed

There are now two drug screening codes for reporting use of a multiplexed screening kit that tests for multiple drugs or drug classes. The Centers for Medicare & Medicaid Service published new HCPCS code G0434 for the multiplexed drug screening to differentiate these tests from those that are more complex. CPT followed with new code 80104 for the same purpose. The descriptors for these new codes follow:

• G0434, "Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter (add modifier QW if you have CLIA certificate of waiver)"

• 80104, "Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure"

Use the G code for Medicare claims, and use the CPT code for other claims. The Medicare Clinical Laboratory Fee Schedule shows an average fee of $20.67.

CMS explained in MLN Matters publication SE1105 (PDF download) that refining the drug screen testing codes and revising the descriptors was done to avoid unnecessary or excessive utilization of code G0431 for relatively simple point-of-care tests that screen for multiple substances. In addition to introducing code G0434, code G0431 was changed from “Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class” to “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter.” If your practice has received denials for claims with dates of service on or after Jan. 1, 2011, that use code G0431QW for tests conducted with the kits listed in MLN Matters publication MM7266 (PDF download), corrected claims should be submitted with code G0434QW. For dates of service on or after April 1, 2011, claims that use code G0431QW will be denied. 

Also effective Jan. 1, 2011, code G0430 has been deleted and replaced with code G0434. Therefore, the code G0434QW replaces G0430QW. 

G0434 should be used to report very simple testing methods, such as dipsticks, cups, cassettes and cards, that are interpreted visually or with the assistance of a scanner, or that are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices). This code should also be used to report any other type of drug screen testing using test(s) that are classified as Clinical Laboratory Improvement Amendments (CLIA) moderate complexity test(s), keeping the following points in mind:

• G0434 includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups, cards, cassettes, etc., that are not CLIA-waived.

• Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver should bill using the QW modifier.

• Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation should not append the QW modifier to claim lines.

• Only one unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on claim lines.

Note that the "per encounter" reporting for G0434 doesn't prevent reporting when a patient is tested in two different settings, such as when a patient tested in the physician's office in the morning later reports to the emergency department and receives a second test.

The MLN Matters publication mentioned earlier (MM7266) also provides a listing of the drug kits that should be reported using the new code G0434 with the QW modifier to signify the test's waived status. Each quarter CMS publishes a list of all test products with CLIA-waived status. Providers may use this list to determine if a particular test product can be appropriately performed by a laboratory with a CLIA waiver and is eligible to be billed using the QW modifier. However, the currently displayed list is from Jan. 5, 2010. You can view the most recent list as provided to the Medicare contractors in Medicare CR7266 (PDF download).

If you are unsure about Medicare coverage of drug screening tests, this information is available from the Medicare Coverage Database and the Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report dated January 2011. I found local coverage determinations for qualitative drug screens posted by National Governments Services Inc., First Coast Service Options Inc., and Palmetto GBA by searching the term "drug screen" in the Medicare coverage database. 

I may have just set the record for the most links in a Getting Paid blog, but I'm sure my drug screen would come out clean. I just like to provide the sources for further information and to help you and your staff keep up with these ever-changing codes and coverage decisions.

Monday Jan 31, 2011

Like a shot in the arm – or not

Jan. 1, 2011 brought quite a few changes to primary care. Some are good. Others that should be good are overly complex (if you have looked at the Medicare annual wellness visit requirements, you know what I mean) or lack acceptance among payers, which is the problem with the new pediatric vaccine administration codes, the subject of this post.

The new pediatric vaccine administration codes were developed to recognize the physician work of counseling patients about each component of combination vaccines. I provided details about these codes in a previous blog. I have heard from some practices that they have seen increased payment for the vaccine administrations from some payers. Unfortunately, other payers are not yet on board with the need to make provision of childhood vaccines an affordable endeavor.

Here is some disappointing but important guidance from the CDC regarding Vaccines for Children (VFC) payment:

In the VFC program, the regional vaccine administration fee cap rates were established on a per-vaccine basis, not on a per-antigen or per-component basis. Under current interpretation of CMS policy, the administration fee for the VFC program will continue to be based on a per-vaccine basis and not on a per-antigen or per-component basis. CMS is looking closely at the VFC administration fee cap to ensure that it keeps up to date with changes in underlying costs of providing vaccines and with medical practice. CMS anticipates updating the fee cap in the near future, and is also examining the larger reimbursement structure of the VFC program. In the meantime, state Medicaid agencies can increase the amount they pay providers up to their regional cap by submitting a State Plan Amendment, as most states are currently paying providers rates that are below their state caps. In addition, a state could choose to establish different rates, up to their regional cap, for a vaccine with multiple antigens and those that are single components.

VFC-enrolled providers may not charge a vaccine administration fee to VFC-entitled children that exceeds the regional administration fee cap per dose of vaccine.

Providers are encouraged to use the new code 90460 for the administration of a vaccine under the VFC program. If code 90461 is used for a vaccine with multiple antigens or components, it should be given a $0 value for a child covered under the VFC program. This applies to both Medicaid-enrolled VFC-entitled children as well as non-Medicaid-enrolled VFC-entitled children (i.e., uninsured, underinsured, and American Indian or Alaska Native children not enrolled in Medicaid).

Also, here's what you need to know about private payers' handling of these claims: Make sure that the person who reviews your payments watches for the number of units allowed by payers. Some are substantially limiting the payment for code 90461. For some this is a system error that is to be corrected, but not for all. One payer's policy blatantly states that it will pay for only one unit per date of service for the primary vaccine administration, 90460, and only 3 units for "additional injections" using code 90461. In other words, the payer is ignoring the per-component-oriented descriptors in CPT 2011. The payer goes on to say, "Maintaining the 'per administration/injection' definition from the 2010 immunization administration codes (90465/90466, 90471/90472) will allow a budget-neutral conversion. The 2011 allowances will reflect a 1% increase." Apparently this payer has never heard that HIPAA prohibits changing the code descriptors. I wonder if the payer's premiums and profits are "budget neutral."

But I didn't write this to depress you. Be aware that the AAFP (and the American Academy of Pediatrics, which has invested extensive time and effort in acceptance and payment of the new codes) is advocating for fair and correct payment of these codes. And as mentioned previously, some payers did begin paying the codes as intended on Jan. 1. We will keep working on the rest.

Wednesday Nov 17, 2010

Vaccine administration: A little good news for little folks and their doctors

If you provide pediatric vaccines in your practice, you have no doubt noticed the increase of combination vaccine products and a related decrease in your payment for vaccine administration services. The good news is that the CPT Editorial Panel and the Centers for Medicare & Medicaid Services (CMS) also noticed. New codes will allow reporting of the administration service for each vaccine component beginning in 2011. Even better, CMS published relative value units (RVUs) for these codes – even though they will not typically be reported for Medicare patients.

The new codes are 90460 and 90461. These codes should be reported for physician counseling (or that of another qualified health care professional) and administration of vaccines to children through age 18. Code 90460 is reported for administration of a single component vaccine and/or for the first component of a multiple component vaccine. Code 90461 is reported for each additional component of a multiple component vaccine. For example, MMR vaccine has three components, so administration of this vaccine would be reported with one unit of 90460 and two units of 90461.

CMS assigned RVUs to these codes by crosswalking them with the values of the adult vaccine administration codes 90471 and 90472. This means that new code 90460 has the same RVUs as 90471, and each unit of 90461 has the same RVUs as 90472. Beats getting one administration fee that was valued the same as 90471!

AAFP Coding Resources web pages have been updated to provide more information on these new codes and the guidelines for reporting them.

More to come on CPT code changes for 2011 in your January/February issue of Family Practice Management!

Friday Oct 08, 2010

Accountable care organizations and the future of physician payment

This week, the Federal Trade Commission (FTC), the Centers for Medicare and Medicaid Services, and the Office of the Inspector General in the U.S. Department of Health and Human Services (HHS) discussed legal issues related to accountable care organizations (ACOs) during a public workshop in Baltimore.

As promised in the meeting agenda, an FTC panel debated circumstances under which independent health care providers participating in an ACO could engage in price point negotiations with private payers without running afoul of federal antitrust laws that prohibit price-fixing. Also, panel participants explored different ways in which the HHS secretary could exercise waiver authority or create new exceptions and safe harbors related to the physician self-referral law, the federal anti-kickback statute, and the civil monetary penalty law, for the purpose of encouraging the creation and development of ACOs. The AAFP submitted comments that were included in the meeting record, and the Academy will continue to track the progress of the issues discussed.
As I listened to the workshop and as I have thought about it since, my thoughts had less to do with how ACOs might be facilitated and more to do with what they might mean for coding by and payment of family physicians.  Regarding coding, I am inclined to think that ACOs will de-emphasize the importance of procedure and service coding while heightening the importance of diagnosis coding. My reason for thinking so is that I expect ACOs will be paid on something other than a fee-for-service basis and, in turn, will pay physicians accordingly. When payment is made, for example, on an episode-treatment or global capitation basis, coding of each individual service becomes much less important than it is under fee-for-service. At the same time, appropriate risk adjustment of global capitation or delineation of episodes of care will depend, at least initially, on correct and complete coding of each patient's condition(s), which is all about diagnosis coding.
Regarding the payments themselves, I am optimistic that family physicians can do well in an ACO model of health care delivery. Family medicine has long touted its value, essentially arguing that nobody can do it better for less. ACOs, according to proponents, are all about cost-effectiveness, which suggests that they will depend on family physicians to succeed. That dependency should create leverage for family physicians to be paid at a level that is commensurate with the value that they bring to the ACO. Of course, this assumes family physicians exercise this leverage and choose to play a key role in the formation and ongoing governance of ACOs. 
Admittedly, this is all a bit of crystal ball gazing on my part, and as my 401(k) results will attest, crystal ball gazing is not my strong suit. As in most matters, only time will tell, but I'd like to hear your predictions. What do you think?

Thursday Oct 22, 2009

You might be a coding and payment geek if . . .

The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people.  So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:

10.  The first thing you associate with December is the arrival of the new CPT book.

9.  You actually get excited when your new coding books arrive.

8.  You wonder why the toy doctors bag you bought your kid doesn't include a claim form.

7.  You worry your family physician is undercoding your visit.

6.  You consider the Federal Register light reading.

5.  You write to CMS more than to your own mom.

4.  You actually understand Medicare's Sustainable Growth Rate formula.

3.  You collect past issues of CPT Assistant on eBay.

2.  When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.

 And the number one sign that you might be a coding and payment geek:

1.  You actually understood the humor in this blog post!

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