Evaluation And Management Services Provided On The Same Date As Vaccine Administration
When an evaluation and management service is provided on the same date as a prophylactic immunization, modifier -25 may be appended to the code for the evaluation and management service to indicate that this service was significant and separately identifiable from the physician’s work of the vaccine counseling/administration.Example: A patient presents for a visit to evaluate the control of his/her diabetes and at the same visit receives an influenza vaccine administration. A physician might report code 99213-25 with diagnosis code E11.9 in addition to the appropriate flu vaccine and administration codes.
Billing Considerations For Part B Vaccines
Whether participating or non-participating in Medicare, physicians must accept assignment of the Medicare vaccine payment rate and may not collect payment from the beneficiary for the vaccine.
Non-participating physicians may choose not to accept assignment on the administration fee. When a non-participating physician or supplier provides the services, the beneficiary is responsible for paying the difference between what the physician or supplier charges and the amount Medicare allows for the administration fee. The limiting charge provision does not apply to the influenza benefit.The influenza and pneumococcal vaccines and the administration of these vaccines are not subject to the Medicare Part B deductible or co-insurance. Medicare pays at 100% of the allowable amounts. However, the Hepatitis B vaccine and administration are subject to the deductible and co-insurance. Medicare pays at 80% after the patient has met their Part B deductible.Medicare will pay two administration fees if a beneficiary receives both the influenza virus and the pneumococcal vaccine on the same day.Claims for the hepatitis B vaccine must include the name and NPI of the ordering physician, as Medicare requires that the hepatitis B vaccine be administered under a physicians order with supervision. This is not necessary for the influenza and pneumococcal vaccines for which Medicare does not require a physician’s order or supervision.
Summary Of Information Contained In This Naci Statement
The following highlights key information for immunization providers. Please refer to the remainder of the Statement for details.
1. What
Streptococcus pneumoniae is a bacterium that can cause many types of diseases including invasive pneumococcal disease , and community-acquired pneumonia .
For the prevention of diseases caused by S. pneumoniae in adults, two types of vaccines are available in Canada: pneumococcal 23-valent polysaccharide vaccine containing 23 pneumococcal serotypes and pneumococcal 13-valent conjugate vaccine containing 13 pneumococcal serotypes.
NACI has been tasked with providing a recommendation from a public health perspective on the use of pneumococcal vaccines in adults who are 65 years of age and older, following the implementation of routine childhood pneumococcal vaccine programs in Canada.
2. Who
Information in this statement is intended for provinces and territories making decisions for publicly funded, routine, immunization programs for adults who are 65 years of age and older without risk factors increasing their risk of IPD. These recommendations supplement the recent NACI recommendations on this topic that were issued for individual-level decision making in 2016.
3. How
4. Why
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Scenario: Billing For Influenza And Pneumococcal Vaccines
If influenza vaccine and pneumococcal vaccine are administered at the same encounter, can an administration fee be billed for each vaccine?
The Centers for Medicare and Medicaid Services address this question in its guide on Medicare Part B Immunization Billing.
When a beneficiary gets both the seasonal influenza virus and pneumococcal vaccines on the same visit, do I continue to report separate administration codes for each type of vaccine?
Yes, see https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html for individual Change Requests and coding translations for ICD-10. Use separate administration codes for the seasonal influenza virus and pneumococcal vaccines. Medicare pays both administration fees if a beneficiary gets both the seasonal influenza virus and the pneumococcal vaccines on the same day.
1/11/16Pneumococcal vaccine administeredG00091Z23
Complications Of Pneumonia Caused By Covid
Because pneumonia causes the alveoli in the lungs to fill with pus and fluid, breathing can be painful and difficult.
Pneumonia can cause serious health complications, including:
Because COVID-19 attacks the lungs, it would make sense that having COVID-19 would cause lung complications. As of yet, not enough data are available to support this conclusion.
However, as noted above, research does show that COVID-19 can cause severe illness, including pneumonia that can be fatal. A 2020 study by the CDC found that among a group of people with COVID-19, about 70% had complications from pneumonia. Also, people with COVID-19 were twice as likely to get pneumonia compared to people with the flu.
Regarding long-lasting complications from COVID-19, it is still too soon to say for sure whether “long-haulers” are more likely to have underlying chronic medical conditions.
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Vaccines Administered At Well
When vaccines are provided as part of a well-child encounter, the ICD-10 guidelines instruct that code Z00.121 or Z00.129 includes immunizations appropriate to the patient’s age. Code Z23 may be used as a secondary code if the vaccine is given as part of a preventive health care service, such as a well-child visit.ICD-10 for Combination Vaccines
ICD-10 requires only one code per vaccination, regardless if single or combination. Report Z23 for all vaccination diagnoses.
How To Stay Safe
Given that COVID-19 is a respiratory illness just as pneumonia is, it is important to do your best to minimize your risk of contracting COVID-19, which could potentially cause severe respiratory complications.
The same precautions you’ve been taking to stay safe during the COVID-19 pandemic will, of course, keep you safe from developing pneumonia secondary to COVID-19, too. Be diligent about wearing a well-fitting mask, social distancing, and washing your hands.
A few other tips to keep in mind for recovery from pneumonia are to:
- Control your fever with NSAIDs or acetaminophen .
- Drink plenty of fluids to help loosen secretions and to cough up phlegm.
- Avoid taking cough medicines before talking to your healthcare provider first because coughing is one of the ways your body is working to get rid of the pneumonia infection.
- Drink warm beverages like tea or hot water.
- Use a humidifier, and take steamy baths or showers to help open your airway and ease your breathing.
- Stay away from smoke to allow your lungs to heal themselves. If you are a smoker, this would be a good time to think about quitting.
- Get rest. Stay home and take it easy for a while until you feel better and stronger.
These are all things you can do from the safety and comfort of your own home. Taking care of yourself and seeking medical care as needed can help keep you safe from COVID-19.
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Heptavalent Pneumococcal Conjugate Vaccine
A 7-valent pneumococcal conjugate vaccine has been introduced by Wyeth Lederle for use in children. The FDA has approved of this protein-polysaccharide conjugate vaccine for prevention of invasive pneumococcal disease in infants and toddlers.
The American Academy of Pediatrics and the CDC’s ACIP recommended pneumococcal polyvalent vaccine for routine use in all children 2 and under, and for black, Alaskan Native, and Native American toddlers up to age 5, as well as for those with sickle-cell anemia, HIV infection, or other immunodeficiency diseases. For infants, the AAP and ACIP recommends that the vaccine be given in 4 doses at 2, 4, 6, and 12 to 15 months for children who are 7 to 11 months, 3 doses for children who are 12 to 23 months, 2 doses and for children 2 years or older, only 1 dose is needed. See table below.
| Age range | |
|---|---|
| 24 to 59 | 1 |
Pneumococcus is the most frequent cause of otitis media, pneumonia, and bacteremia in children, as well as the principle cause of childhood bacterial meningitis. The most susceptible to pneumococcal diseases are children less than 2 years old. Standard pneumococcal polysaccharide vaccines are poorly immunogenic in this age group. The new protein-polysaccharide conjugate vaccine is immunogenic during infancy and is capable of providing long-term immunity.
License For Use Of Physicians’ Current Procedural Terminology Fourth Edition
You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services . You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.
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How To Code For Immunization Refusal
Documenting and coding for patients’ immunization refusal may be necessary for quality initiatives and continuity of care. Several HCPCS and ICD-10 codes are relevant and may be used appropriately depending on specific payer and practice guidance for coding immunization refusal:
For influenza vaccine refusal when the reason is documented, HCPCS code G8483, “Influenza immunization was not administered for reasons documented by clinician.”
For pneumococcal vaccine refusal when the reason is documented, HCPCS code G8866, “Documentation of patient reason for not administering or previously receiving pneumococcal vaccine.”
For immunization refusal due to religious belief or group pressure, ICD-10 code Z28.1, Immunization not carried out because of patient decision for reasons of belief or group pressure.
For immunization refusal due to another reason, such as the discomfort of injections, ICD-10 code Z28.21, Immunization not carried out because of patient refusal.
For immunization refusal by a parent or other caregiver for a child, ICD-10 code Z28.82, Immunization not carried out because of caregiver refusal.
Read answers to readers Coding & Documentation questions in every issue of FPM.
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Pneumonia Treatments And Covid
According to the World Health Organization , bacterial pneumonia should be treated with antibiotics, which are usually prescribed at a health center.
If your symptoms are severe, it is important that you call your healthcare provideror seek immediate helpto get the proper treatment. Severe symptoms include:
- Difficulty breathing
- Bluish color in your lips or fingertips
- A high fever
- Cough with mucus that is severe or worsening
Although COVID-19 is caused by a virus, people with the illness can still develop a superinfection, which is a reinfection or secondary infection caused by bacteria. If this happens, antibiotics will be given to the patient. In order to prevent antibiotic resistance, when antibiotics become useless against bacteria, some researchers have suggested following antimicrobial stewardship principles .
Moreover, because severe cases of pneumonia may require treatment at a hospital, healthcare providers must consider the chance that a patient may acquire coinfections in hospitals. So, to be safe and not add to superinfection among hospitalized patients, antibiotics are warranted.
Adding National Drug Codes To Claims
Medicaid plans and private payers may require the inclusion of a vaccine product’s National Drug Code on your claim line for each vaccine product. This can be a bit confusing if the product is labeled with a 10-digit NDC, as HIPAA requires that NDC have 11-digits. To correctly report the NDC in the HIPPA format, you may have to translate the NDC.The common format for submitting an NDC is a number that, if hyphenated, would appear in a 5-4-2 format. Some drug products are labeled in 4-4-2, 5-3-2, or 5-4-1 formats. To change these codes to the 11-digit format, a zero is placed within the product code to create the 5-4-2 format.
Here are some examples showing addition of a zero to create this format:
| 10-DIGIT NDC |
|---|
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Items Of Note About Codes 90460 And 90461
To correctly report vaccine counseling and administration with these codes, it is important to recognize what the codes do and do not include.
- These codes are limited to immunization administration, meaning purchased vaccine products must be separately reported.
- A face-to-face service where a physician or other qualified health care professional provides counseling to the patient and/or caregivers is required to report 90460-90461.
- In the absence of counseling, the administrations must be reported with codes 90471-90474.
- 90460-90461 are reported for administration to patients 18 years of age and under.
- Code 90460 is reported for each separate administration of single component vaccines and/or first component of a combination vaccine.
- When reporting administration of combination vaccines, code 90460 is reported for the first component and add-on code 90461 is reported for each additional component .
- Note that route of administration does not matter, since the codes include via any route of administration.
Adults Aged 65 Years And Older
A randomized placebo-controlled trial of 13-valent pneumococcal conjugate vaccine was conducted in about 84,500 adults aged 65 years and older, with no particular risk factors. Four years on average after vaccination, there was no reduction in either mortality or the overall incidence of community-acquired pneumonia. It was necessary to vaccinate about 1,000 individuals in order to prevent 1 case of vaccine-type pneumococcal pneumonia during the 4-year follow-up period .
In 2019, the Centers for Disease Control and Prevention updated the recommendations of the Advisory Committee on Immunization Practices for use of 13-valent pneumococcal conjugate vaccine . PCV13 vaccination is no longer routinely recommended for all adults aged 65 years and older. Instead, shared clinical decision-making for PCV13 use is recommended for persons in this age group who do not have an immunocompromising condition, CSF leak, or cochlear implant and who have not previously received PCV13. If a decision to administer PCV13 is made, it should be administered before PPSV23. The recommended intervals between pneumococcal vaccines remain unchanged for adults without an immunocompromising condition, CSF leak, or cochlear implant . PCV13 and PPSV23 should not be co-administered. ACIP continues to recommend PCV13 in series with PPSV23 for adults aged 19 years with immunocompromising conditions, CSF leaks, or cochlear implants .
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Study Population And Data Sources
The Hospital Discharge Data System of the Tennessee Department of Health receives information from UB-92 forms on all inpatient discharges from Tennessee hospitals. Each form contains information on patient diagnoses, procedures performed on the patients, charges for services provided, and selected patient demographics. Hospitalization data from one large academic hospital were used to recode pneumonia hospitalizations identified from 2 periods: 1 year before and 1 year after implementation of ICD-10-CM.
Pneumonia definition
We based our algorithm to identify hospitalizations for all-cause pneumonia in the HDDS data on that used by Griffin et al to analyze national pneumonia trends. The algorithm required a first-listed discharge diagnosis of pneumonia or a first-listed discharge diagnosis of meningitis, septicemia, empyema, or acute respiratory failure in addition to a diagnosis of pneumonia in another diagnostic field.
The ICD-9-CM pneumonia algorithm was translated to an ICD-10-CM algorithm using General Equivalence Mappings . The National Center for Health Statistics, Centers for Medicare & Medicaid Services, American Health Information Management Association, American Hospital Association, and 3M Health Information Systems developed GEMS as a publicly available reference map, to aid in navigating the complex meanings between code sets., Codes used for this study are listed in
Medicare Part D: Vaccine Coverage
Payment for Part D-covered vaccines and their administration are made solely by the participating prescription drug plan. This includes all preventive vaccines not covered under Medicare Part B.
When providing a Part D covered vaccine to a Medicare patient, the physician should charge the patient for the vaccine and its administration. To facilitate the patient’s reimbursement by his or her Part D plan, the physician’s office should complete a CMS-1500 claim form for the vaccine and administration service and give it to the patient to file as an unassigned, out-of-network claim.Some patients may also request a prescription for preventive vaccines and their administration to meet their Part D plan requirements to have this prescription filled by contracted providers .
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