The goal of immunization providers is to ensure that vaccines reach all people who need them. Accurate vaccine coding increases opportunities for enhanced/appropriate reimbursement, reduces audit and liability risks, and improves information flow. Various vaccine code changes have come into effect starting January 1, 2017. Expert medical coding services are available to help providers keep track of these updates, plan for the implementation of the new and revised codes, and submit accurate claims.
Highlights of Vaccine Coding Updates 2016-2017
- Revisions to age specifications in influenza code descriptors: Codes 90655-90658, 90661, and 90685-90688 have been revised to include dosage in place of age in their descriptors. The American Academy of Pediatrics (AAP) gives the revised codes as follows:
|Revised Influenza codes
||2016 – Age of Patient
||January 1, 2017 – Dosage
|90655, 90657, 90685, and 90687
|90656, 90658, 90686, 90688
||Older than 3 years
- 90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use
- 90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use
- 90657 Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use
- 90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
- 90661 Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
- 90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use
- 90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use
- 90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use
- 90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use
- Revision of descriptor for code 90661: CPT code 90661 has been revised to clarify that it represents a trivalent vaccine and to differentiate this vaccine from a quadrivalent product. Formerly, 90661 was used for flucelvax.
- New code 90674: This new influenza code – flucelvax – which came into effect on January 1, 2017 represents quadrivalent cell cultured influenza vaccine indicated for use in those 4 years of age and older:
- 90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
- Vaccine Administration Codes 90460-90474: For proper billing and payment, each vaccination claim needs two codes: an administrative code and a vaccine code. Vaccine administration codes are selected based on what vaccines were administered and how many vaccinations were given, the route of administration, the number of components in each vaccine, and whether or not the physicians provided counseling. The vaccine administration codes are:
- 90460 – Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered.
- 90461 – Each additional vaccine or toxoid component administered (to be listed separately in addition to code for primary procedure.
- 90471 – Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
- 90472 – Each additional vaccine (single or combination vaccine/toxoid) (to be listed separately in addition to code for primary procedure
- 90473 – Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
- 90474 – each additional vaccine (single or combination vaccine/toxoid) (to be listed separately in addition to code for primary procedure)
When reporting the administration of a vaccine, the evaluation and management (E/M) code separately, if appropriate. Modifier 25 should be appended to the E/M code, as needed.
- Revisions to medically unlikely edits (MUEs): Increase in the number of units of service allowed for vaccine administration has impacted two codes:
- For 90460 MUEs have been revised from 6 to 9 with effect from April 1, 2017
- For 90461, MUEs have been revised from 5 to 8 with effect from July 1, 2016
- Vaccine Coverage for Medicare Part B: G0008 – administration of influenza virus vaccine: Administration of influenza vaccine to Medicare patients should be done using the Health Care Common Procedure Coding System (HCPCS) code G0008.
Note: Under Medicare’s policy, code 99211 (an E/M service not requiring a physician’s presence) is not allowed on the same date as immunization administration.
- ICD-10 Code for immunization: Z23 – encounter for immunization: Z23 is the appropriate ICD-10-CM code for influenza vaccine administration and should be linked to both the vaccine product code and administration code for each immunization.
Implementing Vaccine Code Changes
Physician coding companies closely monitor the release and implementation dates posted and help practices plan for incorporating the new and revised vaccine codes. If there are improper denials of vaccine products that have new or revised codes, a reliable medical billing and coding company will appeal denied claims submitted with appropriate codes. Their expert coding team will use the latest coding resources to help physicians optimize reimbursement for immunization services.
ICD-10 was launched in October 2015 by the World Health Organization (WHO). ICD-10-CM is the United States’ clinical modification of the WHO’s ICD-10. ICD-10 features a much larger number of concepts and codes than its predecessors, and most healthcare providers rely on experienced medical coding companies to submit code claims accurately and maximize reimbursement.
A recent report published by leading provider of market intelligence Future Market Insights analyzes U.S. ICD-10 market trends for the period 2016-2026. The report identifies the two key drivers of the demand for ICD-10 as:
- The need for quality measurement and medical error reduction for the safety of patients
- The need for a large amount of medical data for the purposes of clinical research
Compared to ICD-9-CM, the ICD-10-CM/PCS code set has:
- nearly 19 times more procedure codes
- nearly 5 times more diagnosis codes
- a much larger number of combination codes
By enabling greater specificity in identifying health conditions, ICD-10-CM enables providers to create more precise treatment protocols leading to better patient experiences and improved health outcomes.
ICD-10 also provides more and better data for clinical research trials. This expansive code set allows researchers to measure and monitor health care utilization and the quality of patient care more effectively. Researchers need to have accurate and comprehensive data for clinical trials when tracking potential global epidemics, pandemics and deadly outbreaks, and when making comparisons to evaluate new drug therapies. ICD-10 allows that level of tracking. ICD-10’s improved data and documentation allows researchers to predict trends in healthcare more quickly and provide better information on disease prevention and possible adverse effects.
The Future Market Insights market study classifies the major ICD-10 end users as healthcare providers, coders, IT professionals, insurance carriers and government agencies. The report notes that the ICD-10 implementation has proved very expensive for healthcare providers across the country. This is because each healthcare provider’s chain generally has a minimum of 100 physicians and many other entities.
The Centers for Disease Prevention and Control (CDC) publishes updates of ICD-10 every year and it is crucial that healthcare providers are in the loop. Established medical coding companies ensure that their coding team keeps up to date on ICD-10 trends. They provide cost-effective medical coding services for healthcare organizations and physicians’ practices. Their error-free, timely solutions enable providers to meet compliance and maximize revenue.
As you wrap up an eventful 2016, you need to prepare your medical practice for the changes in store for 2017. For one, there will be 75,625 ICD-10-PCS codes for the fiscal year (FY) 2017, of which 3,651 are new codes and 487 are revised. There are also many CPT coding changes slated for the coming year. Here are some proactive strategies to optimize your documentation and medical billing and coding for success in revenue cycle management.
- Ensure specificity in documentation for coding accuracy: Most providers now rely on outsourced medical coding services, but even the most experienced team can ensure accuracy only if documentation meets current requirements. In other words, the increased specificity of ICD-10 and rules of value-based models of care call for more detailed documentation of medical services. Physicians need to master the techniques of using electronic health records to capture clinical information in a comprehensive way.
- Understand the implications of MACRA: The Medicare Access and CHIP Reauthorization Act (MACRA), 2015 will shift reimbursement from fee-for-service to pay for quality and value of services. Physicians need to understand the impact that this legislation will have on documentation, coding and reimbursement and which will differ by specialty. Practice income can be increased by evaluating all the measures for which data is reported, and selecting and reporting metrics in high performance areas.
- Know the key metrics in revenue cycle management (RCM): The five key metrics in RCM are: Days in Accounts Receivable (AR), Days in (AR) greater than 120 days, Adjusted Collection Rate, Denial Rate, and Average Reimbursement Rate. Of these, the denial rate or the percentage of claims that payers denied is a key marker of how effective your coding and billing practices are. In February 2016, Revenue Intelligence reported that the ICD-10 claim denial rate were low and at a minimum among most hospitals and healthcare providers. However, denial rates could escalate if payers develop “more aggressive medical necessity models”, says a Medical Economics report. The end of the earlier grace period on unspecified ICD-10 codes by the Centers for Medicare and Medicaid Services (CMS) is an example of a more aggressive approach.
- Improve time and resource management: Equip your staff to perform their tasks more effectively and inform them about new standards and expectations. Assign patient benefit verification to an insurance verification specialist. Delegating functions such as patient education and data collection to well-trained assistants can help you save time and make better use of your resources.
- Revamp your medical billing and coding practices: If you do medical billing and coding in-house, see that your staff updates their knowledge and skills. Physicians who rely on medical billing and coding companies need to work as a team with them to enhance revenue cycle management. In fact, outsourcing is proving to be a practical option to drive improvements in coding and reimbursement in the current dynamic scenario.
The bottom line: monitoring the health of your practice is just as important as caring for your patients. A proactive team-based approach can help you better achieve both these goals.
The Centers for Medicare and Medicare (CMS) has released new health insurance market place rules which will take effect from January 17, 2017. Referred to as the “payment notice,” the rule is an annual CMS omnibus rule that covers all the major changes that CMS plans to implement during the next year for the marketplaces, including the federally facilitated exchange (FFE) and federally facilitated Small Business Health Options Program (SHOP) Marketplace. Medical billing companies have taken note of the changes in final rule, according to a Health Affairs report, is focused on strengthening and improving the marketplaces. The rule will impact the MRA/HCC Coding for 2017 and 2018.
The main areas that Medicare’s final rule addresses are as follows:
- Modifications to the ACA’s general market reforms – changes to the five-year ban on market reentry upon withdrawal of an insurer from a market, child age rating, and transitions to Medicare, and changes in the medical loss ratio rules to assist new and rapidly growing plans.
- Changes in the risk adjustment program for 2017 and 2018.
- The 2018 payment parameters (the FFE user fee, premium adjustment percentage, and annual limits on cost sharing).
- Changes in plan benefits (bronze plan changes, gold and silver plan participation requirements, standardized options, and essential community provider and network requirements).
- Eligibility, enrollment and other changes (requirements affecting special enrollment periods, language access, direct enrollment, web-brokers, binder payments, insurance affordability programs, and SHOP participation, and a requirement that insurers make qualified health plans (QHPs) available for the entire year).
- Strengthening marketplace oversight (including new rules governing insurer rescissions, civil money penalties, and decertifications and appeals).
- Final changes to the rules governing special enrollment periods and the CO-OPs.
Beginning in 2017, CMS’ proposed policies will take important steps to strengthen the risk adjustment program, which is one of the Marketplace’s key tools for protecting consumers’ access to high-quality, affordable coverage options. The risk adjustment program is aimed at removing incentives for insurers to provide coverage only for those with lower medical risk factors. Key changes to the risk adjustment program for the next two years are:
- Modifications to the risk adjustment program in 2017 to better measure the cost of enrollees who drop their coverage before the plan year is over
- Use of drug utilization data starting in 2018 to give payers a better idea of the costs involved with insuring certain enrollees
- Spreading the cost of the most expensive enrollees among insurers
- Greater emphasis on demographic variables as compared to medical condition variables to estimate the adult risk adjustment model
HCCs use risk adjustment factors (RAFs) to capture complex health conditions. CMS uses risk adjustment diagnosis codes and demographic data reported for one year to determine payment for the next year based on patient risk scores. Success with HCC coding depends on accurate, specific, and complete diagnosis documentation. Physicians can ensure more accurate coding of chronic conditions and improve their risk adjustment factor scores in 2017 and beyond with the help of medical coding services.
As 2017 rolls in, healthcare providers and medical billing and coding companies should prepare for the changes ahead. Physicians need to take steps to enhance care delivery as well as revenue cycle management. Here are some New Year resolutions to help physicians plan ahead and improve their practice:
- Prepare for new ICD-10 codes: The ICD-10 coding system for fiscal year 2017 will have thousands of new codes – 1,900 diagnosis codes and 3,651 hospital inpatient procedure codes. So it’s crucial that medical coding and billing teams are trained on the new/revised codes and knowledgeable about their use. Besides knowing how to apply the numerous coding updates, physicians should also make sure all documentation meets the highest level of specificity.
- Make sure you are up-to-date on your CPT coding: Every year, January 1 ushers in new, revised and deleted Current Procedural Terminology (CPT) codes. Partnering with companies that provide medical coding services will help ensure that your practice is current and compliant with all the CPT updates for 2017.
- Review patients’ insurance coverage: Reviewing your patients’ insurance plans is crucial as plans change and deductibles are reset every year on January 1. Insurance eligibility verification provides important information such as whether patients’ plans are valid and current, and what their copays and deductibles are. Rather than have your staff spend time on this task, hire an insurance verification specialist to handle verifications and prior authorizations. Patients should be educated on their financial responsibility, which can make them more willing to pay.
- Prepare for the Merit-Based Incentive Payment System (MIPS): On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) released the final rule to implement MACRA’s MIPS and advanced alternative payment models (APMs). While 2017 is the transition year, many of the requirements will continue and expand in future reporting years. So determining the strategies to help your practice succeed in the coming years should begin now. Staying current with the latest requirements, important dates and information will ensure that your practice avoids penalties and maintains its productivity levels.
- Better engage patients in their healthcare: In the post-ACA era, the focus is on the quality of care. So plan ahead to provide patients with quality care as well as a positive experience. Many electronic health records (EHR) systems have website portals to better engage patients in their healthcare. By explaining the benefits of the portal and encouraging adoption, physicians can deliver better care to their patients. They can also use social media to interact with patients and motivate them to track and improve their health care habits.
- Manage stress: A 2015 Mayo Clinic study showed that over 50 percent of US Physicians now suffer at least one symptom of burnout. Defuse stress by finding time for activities and hobbies you enjoy. Outsourcing demanding tasks such as medical billing and coding can ease your administrative burdens, reduce overhead costs, and improve workflow.
With the anticipated changes in federal policy in 2017, it is critical that physicians take proactive measures to keep pace with the developments and continue to be patient focused, while utilizing their resources more effectively to improve their bottom line.