Vaccination Coding

Join Dr. Sharon Brangman, from SUNY Upstate Medical University and Dr. Robert Zorowitz, from Humana, as they discuss Medicare coverage for vaccinations and the various codes used when reporting vaccinations and vaccination counseling.

To view a transcript click here then select the transcript tab. 

Transcript

Sharon Brangman, MD, AGSF: Hello, I'm Dr. Sharon Brangman, Distinguished Service Professor and Chair of the Department of Geriatrics at Upstate Medical University, where I also direct the SUNY Upstate Center of Excellence for Alzheimer's Disease. Today I'm here with Dr. Robert Zorowitz, who is regional Vice President at Humana. We're gonna discuss some of the key points from the AGS' Older Adult Vaccine Initiative with a specific focus on Coding for Vaccinations.

Dr. Zorowitz, I know a lot of clinicians have questions about how do we code for vaccination, and I was wondering if you could review some of the key points for our audience. 

Robert A. Zorowitz, MD, MBA, AGSF, CMD: I would be delighted to do that, Dr. Brangman. First, I, I just wanna make a few points because vaccination coding can appear complicated on the surface, but it really isn't that complicated. So, so bear with me. 

So first, Medicare Part B and Medicare [00:01:00] Part D are a little different. So Medicare Part B by statute covers vaccines for influenza, pneumococcal pneumonia, and hepatitis B. And Part B covers other vaccines only if directly related to an illness or an injury. So for instance, if someone requires a tetanus shot after an injury, but it would not cover a prophylactic tetanus shot on a routine basis. All other vaccines that are recommended by CDC's Advisory Committee on Immunization Practices, otherwise known as ACIP, would be covered by Part D. 

The important thing about coding and what makes it a little confusing is that reporting vaccines usually require two codes, one for the specific vaccine product and a second for the administration. And most vaccine products are reported with a specific CPT code except for flu, pneumococcal [00:02:00] pneumonia, and hepatitis B. For these which are reported to Medicare Part B, CMS has their own codes known as Healthcare Common Procedure codes or HCPCS codes. These usually begin with a G, and our slide set has listed these.

The other thing that's important to know is that because vaccines change so often and new ones come, the CPT manual may not always be up to date, and the AMA has its own webpage where you can find the most up-to-date codes. So if it's okay with you, I can give you a few examples, a few little scenarios.

Sharon Brangman, MD, AGSF: Yeah. I think that would be very helpful to kind of drive home some of the key points you just mentioned. 

Robert A. Zorowitz, MD, MBA, AGSF, CMD: Okay. So I, I'm gonna try to give two or three examples. 

Let's talk about. A 65-year-old woman who comes into the physician for an initial preventive physical exam or [00:03:00] what we know in the vernacular as the Welcome to Medicare Visit. So of course, to report this visit, as you probably know, the clinician has to complete a series of required components, which include a history review of systems, medications, and a variety of different screens. And let's say her only reported problem is age-related hearing loss, and you un, you know, you recommend that she undergo audiology testing, but she's otherwise healthy. But then you find out as the physician or clinician that she has never had a pneumococcal vaccine and she's due for an influenza vaccine and you recommend both. And she agrees. 

So how do you code these? So it may look somewhat complicated, but it's actually relatively straightforward. So first, the introduction to Medicare visit itself is reported with a so-called HCPCS code or G code G0402.

And then if you are gonna do a screening EKG, you would [00:04:00] use that code. And she has no EKG abnormalities. So you go on. 

Now, each of these two vaccines then require their own codes. So let's say we are gonna do the influenza vaccine and we look up in our little manual or our little list. Now there is a CPT code for influenza.

However, CMS requires that we use its own G code, which is G0008. And again, these are in the slide set that accompanies this curriculum. So you don't need to memorize this. And there is, however, a CPT code for the particular type of vaccine. So, for instance, 90662 is influenza virus vaccine, split virus, preservative free, and hands immunogenicity, et cetera. So I'm not gonna give you the details cuz there are a variety of different codes. [00:05:00] 

Likewise for the administration of the Pneumococcal vaccine, we are required to use a G code, in this case G0009. And then the specific CPT code for the product, which in this case might be Pneumococcal conjugate vaccine 20 valent, which is known as the PCV 20 for intramuscular use, which would be 90677, and again, Don't worry about the particulars. This is all listed in the, in the slides and in, in the manual. 

So let's take another scenario. Again, I realize this might be a little complicated, but it actually isn't. Let's say a 74-year-old woman with diabetes comes for a follow-up visit. You might be the nurse practitioner or the primary care provider, and so she comes in for a routine follow-up visit.

And you perform that visit. Her diabetes is under good [00:06:00] control, so you're going to manage that appropriately. But then she says, you know, I've never had a a pneumococcal vaccine. Well, this is great. This is your opportunity. So we are going to administer the pneumococcal vaccine. Now, how do we code this?

So first step, the office visit itself. Let's say it's a 20 to 29 minute visit, you use CPT code 99213 because you're going to administer a vaccine that's unrelated to the disease. You have to affix the modifier 25, so you are submitting as a claim 99213 with modifier 25. 

For the administration of the pneumococcal vaccine we use that G code, which we mentioned before, G0009. Which would be in lieu of the equivalent CPT code. And then let's say we use again, PCV 20, as we did in the previous [00:07:00] example 90677, which is the pneumococcal conjugate vaccine 20 valent for intramuscular use. Easy. So you're submitting three codes for the visit and for the administration of the vaccine along with the particular product.

Sharon Brangman, MD, AGSF: So this is very helpful because these are real life scenarios that we see every day as we take care of people in the office, and it's important for clinicians to realize that we can bill for these vaccinations if we use the appropriate codes. 

Robert A. Zorowitz, MD, MBA, AGSF, CMD: Yes. And, and, and as I said before, it does appear complicated on the surface.

Once you become familiar with it and you sort of come up with a routine for doing it, it's not that difficult. And the, the curriculum really walks through the process. 

Sharon Brangman, MD, AGSF: So what would happen if, if someone comes in who has an actual injury? So say for example, somebody injures themselves and you [00:08:00] think they need a tetanus shot, how would that change?

Robert A. Zorowitz, MD, MBA, AGSF, CMD: Yeah, that's, that's an excellent scenario. So let's say, oh, a 70, 71 year old gentleman comes in for a follow up of hypertension, but happens to mention that he cut his foot on a jagged piece of metal. So once again, you do the visit and let's say another, you know, this one's longer because he's got a number of comorbidities. You're going over 30, 39 minutes. So we're going to use CPT code for office outpatient 99214. 

But this gentleman who cut his foot on a piece of metal now requires a a tetanus diptheria booster. And therefore we're going to again, affix that modifier 25 to the office code, so 99214 and the modifier 25.

In this case, we're using a CPT code for both the administration and the product. So let's say we're giving [00:09:00] him a tetanus diphtheria booster because it's time he hasn't had one in a few years. We might as well give him both. Tetanus and diphtheria rather than just tetanus. So tetanus and diphtheria toxoids absorb preservative free when administered to individuals seven years or older, and that would be CPT code 90714.

And then we also need to use an administration code, which 90471 would indicate immunization administration, one vaccine. And therefore here, instead of using those G codes, which we use for flu shots or pneumococcal vaccines or hepatitis, here we're actually using the CPT code for both the product and for the administration itself.

Sharon Brangman, MD, AGSF: So that's very helpful. And as you mentioned earlier this information is readily available in your slide deck that you made for the AGS' Older [00:10:00] Adult Vaccine Initiative. And also the vaccine codes can be found in the CPT Manual or on the AMA's category one vaccine webpage, so that these resources are readily available to any of our clinicians who want to start working on incorporating vaccine coding into their clinical practice. 

Are there any other points that you would like to make today, Dr. Zeth? 

Robert A. Zorowitz, MD, MBA, AGSF, CMD: The only other point that I would make is that in addition to reporting these codes, when you submit claims for these visits, of course one has to also submit ICD-10 codes. And usually one would use Z23: encounter for immunization, but there are also specific ICD-10 codes for pneumococcal pneumonia vaccine, influenza, hepatitis B, and they can be reported as well. 

We didn't get into the, the whole subject of covid 19 vaccines. [00:11:00] Those get a little bit more complicated because the codes indicate not only the specific product, but also whether it's a first, second, or third dose.

And again, the AMA maintains a webpage that lists all the vaccines and their appropriate codes, both for COVID 19 and, and other conditions. It's all there and it's, it's listed and the links are in the curriculum slide set. 

Sharon Brangman, MD, AGSF: Thank you so much for this important information, infor joining us today, and I would like to remind everyone that we have all of this information in our slide deck that is part of the AGS' Older Adult Vaccine Initiative. Thank you, Dr. Zorowitz. 

Robert A. Zorowitz, MD, MBA, AGSF, CMD: My pleasure.