coding and electronic billing for vaccines, august 22, 2012. webinar series – part two third-party...

Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments

Part Two: Coding and Electronic Billing for

Vaccines August 22, 2012

2:00 p.m. – 3:30 p.m. EDT

Third-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health

Departments 2012 Webinar Series 2


1. Navigating the Credentialing Process with Health Plans - September 19, 2012; 2:00 p.m. – 3:30 p.m. ET Register at: http://ahip.org/Webinar/ReimbursementforVaccines/

2. Archived Webinars: http://www.ahip.org/Archived-Webinars-

Immunization/

3. Contact Natalie Slaughter at [email protected] with questions.

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Save the Date – AHIP’s 2012 Webinar Series Continues


Webinar Goals

1. Provide public health entities with an overview of coding for vaccines and immunization services, best practices and available resources.

2. Discuss existing billing mechanisms for effective billing and claims submission.

3. Review the electronic claims submission of a large health plan.

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Presenters

1. Barbara Lardy, M.P.H., Senior Vice President, Clinical Affairs and Strategic Partnerships, America’s Health Insurance Plans

2. Wayne Rawlins, M.D., M.B.A, National Medical Director, Racial and Ethnic Equality Initiatives, Aetna

3. Katherine Abel, CPC, CPMA, CPC-I, CMRS, Director of Curriculum, AAPC

4. Michele Darnell, Vice President, Secure Exchange Solutions

5. Shannon Montgomery, Aetna Learning Consultant, Communications Production and Education, Aetna

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Webinar Agenda

1. Welcome and Introduction

2. Presentations– Coding Basics– Billing Processes – Aetna’s Electronic Claims Submission

3. Questions and Answers

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Coding Basics for Vaccines and Immunization

Services

Katherine Abel, CPC, CPMA, CPC-I, CMRSDirector of Curriculum

AAPC On behalf of AHIP

7Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments


Disclaimer

CPT® copyright 2011 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association.

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Overview – Coding for Vaccines and Immunization Services– Documentation Guidelines

– CPT® Coding Basics

– ICD-9-CM Coding Basics

– Additional Challenges

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Federal Documentation Requirements for Vaccines1. The name of the vaccine and the manufacturer;

2. The lot number and expiration date of the vaccine;

3. The date of administration;

4. The name, address, title and signature of the person administering the vaccine;

5. The edition date of the Vaccine Information Statement (VIS) and the date the patient or parent receives the VIS.

Source: http://www.aafp.org/fpm/2007/0300/p48.html

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ICD-9-CM Coding Basics for Vaccines – Find the documented diagnosis;

– Determine the main term;

– Look up the main term in the Index to Diseases (Volume 2);

– Find the code in the Tabular List (Volume 1);

– Read all notes associated with the code.

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CPT® Coding Basics for Vaccines Index:

VaccinesAdenovirus…………………………90476-90477Anthrax………………………………………90581

Chicken Pox………………………………..90716 Cholera

Injectable…………………………………90725Diptheria and Tetanus (Td)……....90714, 90718Diptheria Toxoid…………………………….90719

Diptheria, Tetanus (DT)…………………….90702Diptheria, Tetanus, Acellular Pertussis (DTaP)………………………………………..90700

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ICD-9-CM Coding Basics for Vaccines – Diagnosis: Vaccination for DTaP

– Alphabetic Index, Volume 2, look for “Vaccination/prophylactic (against)/diphtheria (alone)/with tetanus/pertussis combined [DTP] (DTaP) V06.2”

– Tabular List, Volume 1, look for V06.1

– Read notes surrounding V06.1

– V06.1 Need for prophylactic vaccination and inoculation against combinations of diseases; Diphtheria-tetanus pertussis, combined [DTP][DTaP]

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– Vaccine immunization administration: (90460, 90461, 90471-90474); and

– Vaccine/Toxoid (90476-90749)

Immunization Administration


90460-90461– Through 18 years of age, any route of

administration, with counseling by physician– Coded by component

90471 – 90474– Does not include counseling– Coded by route – injection vs. intranasal or oral– Coded by vaccine (single or combination)– Non-age specific

Immunization Administration cont’d.


90460-90461– Through 18 years of age, any route of

administration, with counseling by physician– Coded by component

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Vaccine # Components

Admin Codes w/ Counseling

Vaccine Code

DtaP-Hib-IPV, IM 5 90460, 90461 x 4 90698

Rotovirus, 3-dose, oral

1 90460 90680

Pneumococcal, 13v, IM

1 90460 90670



90471 – 90474– Does not include counseling– Coded by route – injection vs. intranasal or oral– Coded by vaccine (single or combination)– Non-age specific

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Vaccine # Components

Admin Codes w/o Counseling

Vaccine Code

DtaP-Hib-IPV, IM 5 90471 90698

Rotovirus, 3-dose, oral

1 90474 90680

Pneumococcal, 13v, IM

1 90472 90670



ICD-9-CM Guideline Section I. C. 18. d. Inoculations and vaccinations

– Categories V03-V06 are for encounters for inoculations and vaccinations.– They indicate that a patient is being seen to receive a prophylactic inoculation against a disease. – The injection itself must be represented by the appropriate procedure code. – A code from V03-V06 may be used as a secondary code if the inoculation is given as a routine

part of preventive health care, such as a well-baby visit.


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Vaccine Vaccine Code Diagnosis Code

DtaP-Hib-IPV, IM 90698 V06.8

Rotovirus, 3-dose, oral 90680 V04.89

Pneumococcal, 13v, IM 90670 V03.82


– Fee based on vaccine not component

– Modifier SL – state supplied vaccine

Source: http://www.cdc.gov/VACCINEs/programs/vfc/projects/faqs-doc.htm#admfees

Vaccines for Children (VFC)



Challenges: Payer Rejection Codes1. No paper standard requirement – payer specific

2. Electronic standards - Washington Publishing Company (WPC) – Version 5010 (http://www.wpc-edi.com/reference/)

– Claim adjustment reason codes– Remittance advice remark codes– Claim status codes

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Challenges: Correct Coding1. Medicare Coverage Database (MCD)

http://www.cms.gov/medicare-coverage-database/overview-and-quick-

search.aspx

– National Coverage Determinations– Local Coverage Determinations

2. Commercial Insurance (BCBS, Cigna, Humana, etc.)– Each have their own medical policies– Example: http://www.bcbst.com/providers/mpm.shtml

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Challenges: ICD-10-CM

1. HHS Secretary issued proposed rule to delay ICD-10-CM Compliance to October 1, 2014.

2. CMS has turned in their recommendations to OMB.

3. May be November before an official date is announced.

4. Immunizations – one code.

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Challenges: Immunizations

1. Coding requirements vary between carriers.

2. Look for medical policy manuals on insurance carrier websites.

3. Keep a notebook of insurance requirement guidelines.

4. When selecting a practice management system, see if these guidelines can be loaded into the system.

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Challenges: Healthcare ProvidersCPT® states:

A “physician or other qualified healthcare professional” is an individual who

is qualified by education, training, licensure/regulation (when applicable),

and facility privileging (when applicable) who performs a professional

service within his/her scope of practice and independently reports that

professional service. These professionals are distinct from “clinical

staff.” A clinical staff member is a person who works under the

supervision of a physician or other qualified healthcare professional and

who is allowed by law, regulation and facility policy to perform or assist

in the performance of a specified professional service, but who does not

individually report that professional service. Other policies may also

affect who may report specific services.

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Challenges: Healthcare Providers1. State scope of practice

– State board of health

2. Insurance contracts– Do they contract PAs and NPs?

3. Other regulations– CMS Policy Manual (http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html)

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Mechanisms for Effective Claims Submission

Michele DarnellVice President

Secured Exchange Solutions On behalf of AHIP



Overview

1. Professional Paper Claim Form (CMS-1500)

2. Electronic HIPAA Claim Transaction (837P)

3. Direct Data Entry (DDE) – Health plans website

4. DDE Using a Web Portal Vendor, e.g. Availity, NaviNet, RealMed, OneHealthPort

5. Billing Process (HIPAA 837P) Managed by a Clearinghouse or Medical Billing Company

6. Roster Billing

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Billing Processes cont’d.

1. Professional paper claim form (CMS-1500):– Standard CMS approved claim form– Form maintained by the National Uniform Claim

Committee (NUCC)

2. Electronic HIPAA claim transaction (837P):– Challenging if not familiar with billing process or

able to transmit electronically

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3. Direct Data Entry (DDE) – Health Plans Website:

– Usually a free service offered by health plans;– Sign onto plan-specific web page; authorization;– Submit required patient and provider

demographic information, the specific service code and contracted charge.

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4. DDE through a Web Portal Vendor: (Availity, NaviNet, RealMed, OneHealthPort):

– Similar to service offered on plan-specific website;

– Added advantage of allowing access to multiple health plans;

– Providers may pay a fee for use of portal; but reduces staff time and other resources.

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5. Billing process (HIPAA 837P) managed by a clearinghouse or a medical billing company:

– Converts billable item(s) into properly formatted 837P transaction;

– Submits transaction to the appropriate health insurance plan;

– Fee for the services may be similar to costs for developing and managing an internal system.

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6. Roster billing – Acceptable alternative to submit immunization

charges on a routine basis (weekly or monthly)

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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments 33

Common CPT/ HCPCSL Codes for Influenza Immunizations– 90655: Influenza virus vaccine, split virus, preservative

free, when administered to children 6-35 months of age, for intramuscular use

– 90656: Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use

– 90657: Influenza virus vaccine, split virus, 6-35 months dosage

– 90658: Influenza virus vaccine, split virus, when administered to individuals 3 years and older, for intramuscular use

Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments 34

Common CPT/ HCPCSL Codes for Influenza Immunizations cont’d. – Q2035: Influenza virus vaccine, split virus, when

administered to individuals 3 years of age and older, for intramuscular use (Afluria)

– Q2036: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)

– Q2037: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirun)


Common CPT/ HCPCSL Codes for Influenza Immunizations cont’d. – Q2038: Influenza virus vaccine, split virus, when

administered to individuals 3 years of age and older, for intramuscular use (Fluzone)

– Q2039: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)

– 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine

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Recommendations

1. If minimal claim volume – DDE through a health insurance plan website may be most efficient approach or roster billing.

2. Mailing paper CMS 1500 claims (first class) may be another low cost option.

– Most health insurers encourage electronic submissions

– Paper claims / mailing adds time to processing and payment

3. If sufficient claim volume, may justify use of medical billing company or establishment of internal infrastructure.

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coding and electronic billing for vaccines, august 22, 2012. webinar series – part two third-party...

Documents

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webinar series

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existing billing mechanisms

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