AAP website posts an overview of changes in vaccination

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IAC EXPRESS <express@...>

Subject: IAC EXPRESS #504

Date: Jan 12, 2005 5:53 PM

IAC EXPRESS: Extra Edition

Immunization news from the Immunization Action Coalition

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Issue Number 504 January 12, 2004

CONTENTS OF THIS ISSUE

1. AAP website posts an overview of changes in vaccination

administration procedure codes and their valuation for 2005

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(1 of 1)

January 12, 2004

AAP WEBSITE POSTS AN OVERVIEW OF CHANGES IN VACCINATION

ADMINISTRATION PROCEDURE CODES AND THEIR VALUATION FOR 2005

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.

**********************

COMPREHENSIVE OVERVIEW: IMMUNIZATION ADMINISTRATION 2005

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.

CPT CODES

There are now a total of eight (8) immunization administration CPT

codes: the four " old " codes (90471-4) plus four " new " codes

(90465-8). Their code descriptors are as follows:

90465 Immunization administration under 8 years of age (includes

percutaneous, intradermal, subcutaneous, or intramuscular

injections) when the physician counsels the patient/family; first

injection (single or combination vaccine/toxoid), per day

(Do not report 90465 in conjunction with 90467)

90466 Immunization administration under 8 years of age (includes

percutaneous, intradermal, subcutaneous, or intramuscular

injections) when the physician counsels the patient/family; each

additional injection (single or combination vaccine/toxoid), per

day (List separately in addition to code for primary procedure)

(Use 90466 in conjunction with 90465 or 90467)

90467 Immunization administration under age 8 years (includes

intranasal or oral routes of administration) when the physician

counsels the patient/family; first administration (single or

combination vaccine/toxoid), per day

(Do not report 90467 in conjunction with 90465)

90468 Immunization administration under age 8 years (includes

intranasal or oral routes of administration) when the physician

counsels the patient/family; each additional administration (single

or combination vaccine/toxoid), per day (List separately in

addition to code for primary procedure)

(Use 90468 in conjunction with 90465 or 90467)

90471 Immunization administration (includes percutaneous,

intradermal, subcutaneous, and intramuscular); one vaccine (single

or combination vaccine/toxoid)

(Do not report 90471 in conjunction with 90473)

90472 Immunization administration (includes percutaneous,

intradermal, subcutaneous, and intramuscular); each additional

vaccine (single or combination vaccine/toxoid)

(Use 90472 in conjunction with 90471 or 90473)

90473 Immunization administration by intranasal or oral route; one

vaccine (single or combination vaccine/toxoid)

(Do not report 90473 in conjunction with 90471)

90474 Immunization administration by intranasal or oral route; each

additional vaccine (single or combination vaccine/toxoid) (List

separately in addition to code for primary procedure)

(Use 90474 in conjunction with 90471 or 90473)

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?

Each one of the aforementioned immunization administration codes

includes

* Administrative staff services such as making the appointment,

preparing the patient chart, billing for the service, and filing

the chart

* Clinical staff services such as greeting the patient, taking

routine vital signs, obtaining a vaccine history on past

reactions and contraindications, presenting a Vaccine Information

Sheet (VIS) and answering routine vaccine questions, preparing

and administering the vaccine with chart documentation, and

observing for any immediate reaction

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.

DOCUMENTATION GUIDELINES

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.

VIGNETTES

Vignette #1:

A 6-year-old patient receives his second hepatitis B vaccine and

the intranasal influenza vaccine in conjunction with his preventive

medicine visit. The physician conducts the vaccine counseling

associated with the both vaccines. The immunization administration

for this visit is reported as follows:

90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose

schedule), for intramuscular use

90465 Immunization administration (percutaneous/intradermal/

subcutaneous/intramuscular) under 8 years of age when

physician counsels the patient/family; first injection

90660 Influenza virus vaccine, live, intranasal use

90468 Immunization administration (oral/intranasal routes of

administration) under 8 years of age when physician counsels

the patient/family; each additional administration

The preventive medicine visit and any other services provided

during the encounter would be reported separately.

Teaching Point:

* 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.

Vignette #2:

A 9-year-old patient receives her second MMR vaccine and her third

hepatitis B vaccine. The physician conducts the vaccine counseling

associated with both vaccines. The immunization administration for

this visit is reported as follows:

90707 MMR vaccine, live, for subcutaneous use

90471 Immunization administration (percutaneous/intradermal/

subcutaneous/intramuscular); one vaccine

90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose

schedule), for intramuscular use

90472 Immunization administration (oral/intranasal routes of

administration); each additional vaccine

Evaluation and management (E/M) or any other services provided

during the encounter would be reported separately.

Teaching Point:

* 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.

CPT CODE VALUATION ON THE MEDICARE RESOURCE-BASED RELATIVE VALUE

SCALE (RBRVS)

[iAC EXPRESS editor's note: The table titled CPT Code Valuation on

the Medicare Resource-Based Relative Value Scale (RBRVS) cannot be

reprinted in this IAC EXPRESS Extra Edition. To access the table,

go to: http://www.immunize.org/aap/rbrvstable.pdf]

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?

A. Relative value units (RVUs) for the oral/intranasal immunization

administration codes (90467, 90468, 90473, and 90474) are not

published on the 2005 Medicare physician fee schedule due to a

Medicare payment policy that classifies oral/intranasal drugs as

" self-administered " and, therefore, not covered under the Medicare

program. Medicare classifies such codes with status indicator " N "

(noncovered) and has not yet committed to publishing RVUs for

Medicare noncovered services. The Academy has been advocating

strongly for CMS to publish the RVUs for such noncovered services,

citing the following reasons:

(1) Non-Medicare Use of RBRVS

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.

(2) RUC Recommendations

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.

(3) Public Health Concerns

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 Walsh at lwalsh@... or

(800) 433-9016 Ext. 7931.

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To obtain the Comprehensive Overview: Immunization Administration

2005 from the AAP website, go to:

http://www.aap.org/visit/ImmunizationAdmin2005.doc

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