The Centers for Disease Control and Prevention (CDC) has confirmed three cases of human infection with swine origin influenza A (H3) viruses in Pennsylvania, as of Sept. 6. According to the Pennsylvania Department of Health, all three infected children under age 10 attended the Washington County Agricultural Fair the week of Aug. 13-20.
“It′s pretty rare to see human infections with swine flu viruses. CDC gets reports of about 5 cases of human infections with swine flu viruses each year,” said Lyn Finelli, chief outbreak investigator for CDC′s Influenza Division. “Most of the time, these cases occur after close contact with pigs and seldom spread onward from the first person infected.”
The viruses isolated in Pennsylvania are a little different from previously seen swine origin influenza A (H3) viruses in that all have acquired a gene from the human 2009 H1N1 viruses, the CDC said.
The investigation in Pennsylvania will continue to determine if more people are sick or if there is ongoing spread of this virus in the community.
“Fortunately,” Finelli said, “it does not look like there is current spread in the community and so far, illness associated with these viruses has not been especially severe. Two of the patients are fully recovered and the third is recovering.”
Finelli said that although this season’s flu vaccines will not protect against an infection with a swine origin virus, the antiviral drugs oseltamivir and zanamivir, which are used to treat infection with human seasonal viruses, also show activity against these viruses.
For Medicare beneficiaries, oseltamivir and zanamivir are for use in a Medicare-approved demonstration project, and reported with the appropriate HCPCS Level II code:
||Zanamivir, inhalation powder, administered through inhaler, generic, per 10 mg
||Oseltamivir phosphate, oral, generic, per 75 mg
||Zanamivir, inhalation powder, administered through inhaler, brand name, per 10 mg
||Oseltamivir phosphate, oral, brand name, per 75 mg
“If [clinicians] see influenza like illness and suspect influenza and there is a history of swine exposure, [they] should consider treating their patients with influenza antiviral medications, even before they get a positive influenza test result. This is especially true if there is little seasonal influenza activity, which is the case in most of the United States at this time,” Finelli said.
October 14th, 2011
To better conform to recent Center for Disease Control and Prevention (CDC) recommendations for the prevention and control of influenza, the Centers for Medicare & Medicaid Services (CMS) recently revised current language regarding the timing of seasonal influenza vaccine administration.
CDC recommendations state that influenza vaccination efforts should begin as soon as the seasonal vaccine is available and continue through the influenza season.
Typically, this vaccine is administered once a “flu season,” but the beginning and duration of the influenza season cannot be precisely determined. Because there is no yearly limit, contractors determine whether such services are reasonable and allow payment if appropriate.
When deemed appropriate, Medicare Part B provides 100 percent coverage for the influenza vaccine and its administration as a preventive service. The Part B deductible and coinsurance do not apply. A physician’s order is not required, nor is a physician’s supervision.
Source: CMS Transmittal 2253, Change Request (CR) 7453, issued July 8
July 15th, 2011
By Lisa Jensen, MHBL, FACMPE, CPC
According to the April 2011 Parents Magazine, 40 percent of school age children are behind on their vaccines. Measles, mumps, whooping cough, and other diseases once nearly eradicated in the United States are again on the rise. The culprit is thought to be a loss of faith in the safety and efficacy of vaccines. News headlines and Internet chatter warn of vaccines leading to autism, asthma, attention deficit hyperactivity disorder (ADHD), diabetes, etc. On the other side of the debate are many studies pointing to evidence that vaccines and their components are safe and effective.
Parents trying to determine what is best for their child often turn to the child’s pediatrician or other health care provider for advice. With all the conflicting information to sift through, providers often must spend a lot of time counseling parents prior to administering vaccines. Complete, proper coding ensures this time is fairly reimbursed.
Vaccine Timing Is Important
Each year, based on the most recent scientific data, disease experts recommend a vaccine schedule to best protect children in the United States. Changes, if needed, are announced in January. The schedule is approved by the American Academy of Pediatrics (AAP), the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians (AAFP).
The recommended vaccine schedule is influenced by several age-specific factors, such as risks for disease and complications, responses to vaccination, and potential interference with the immune system by passively transferred maternal antibodies. Taking these factors into account, vaccinations are scheduled for the earliest age group for which efficacy and safety have been demonstrated.
For many vaccines, three or four doses are needed to fully protect a child. To work best, the doses need to be spaced out. Although the vaccine schedule is considered ideal, there are exceptions for some children, including those who have an allergic reaction to an ingredient in the vaccine, a weakened immune system due to illness, a chronic condition, or are undergoing another medical treatment.
Code Administration in Two Parts
The services associated with administration of vaccines are coded and billed in two parts: one code for the vaccine and another for the administration. You must report both parts of the service to ensure accurate coding and reimbursement.
For 2011, the American Medical Association (AMA) introduced two new codes in CPT® for vaccine administration:
90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component
+90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (List separately in addition to code for primary procedure)
The new codes differ from the previous (now deleted) codes 90465-90468 in several ways. Most importantly, the previous codes were reported per immunization, whereas the new codes require you to report each component separately. A component refers to all antigens in a vaccine that prevent disease(s) caused by one organism. Combination vaccines are those that contain multiple vaccine components.
The table below shows the differences between the old and new administration codes.
||90460-90461 (New Codes)
||90465-90468 (Deleted Codes)
|Routes of administration
||Use for all routes of administration
||Codes differed based on route of administration
||Immunization was single or combination
||18 years and younger
||Younger than 8 years
||Required by physician or “other qualified health care professional”
||Required by physician
These changes mean that vaccine administration coding will look very different than it has in the past. More claim lines will be required to report the same services, and counting the number of components will be different now when we count vaccines. For example:
- HPV vaccine would be one component and coded as 90460
- Td would be two components and coded as 90460, 90461
- DTaP or Tdap would be three components (90460, 90461, 90461)
- DTaP-Hib would be four components (90460, 90461, 90461, 90461)
- DTaP-Hib-IPV would be five components (90460, 90461, 90461, 90461, 90461)
Counseling Is Critical
Counseling by a physician or other qualified health care professional (e.g., physician assistant or nurse practitioner) at the time of the administration is critical and a requirement of 90460 and 90461. Let’s define counseling.
CPT® requires each service billed to be fully and independently supported by medical record documentation, but does not go into specific detail about exact requirements to support the counseling of each component. Providers must provide face-to-face counseling, and then choose the format that works for them and their clinic, while still making it crystal clear which vaccine components were counseled on, and what that entailed.
For example, a note might include all vaccine components recommended at this visit, a notation that each component had counseling, and any issues discussed specific to those patient risk factors.
The documentation should support the time and effort associated with administering combination vaccines. Photocopying a statement, stamping a statement, or cutting and pasting templated documentation should be avoided. If you are concerned about your specific templates or documentation format, check with your payers to see what their payment policies are surrounding these new codes.
Some Administration Codes Carry Over
Vaccine administration codes 90471-90474 carry over from previous years, to be used for patients 19 years and older when the provider does not provide counseling, or if the health care professional providing the counseling does not meet state requirements for an “other qualified health care professional.”
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
+90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
+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)
Counseling and Non-counseling Codes Can Be Mixed
If counseling is provided for some, but not all, vaccine/toxoid components to be administered, new administration/counseling codes 90460-90461 and carry-over administration codes 90471-90474 may be reported together to accurately reflect the services rendered. For example, if counseling is performed for HPV vaccine but not for an influenza vaccine provided at the same visit, report 90460 for the HPV and 90472 (or 90474, if the second, non-counseled vaccine is administered orally or intranasally) for the influenza vaccine.
Another circumstance might occur if counseling was provided at an earlier visit, the parent has new questions or concerns at the return visit, and the physician or other qualified health care professional is asked to address these concerns. It would be appropriate to report code 90460 at the administration of a series vaccine if counseling is clearly documented during a return visit.
As a complete coding example (including administration and vaccine reporting), consider the following case:
A patient presents for her two-month well-child visit and is vaccinated for DTaP-Hib-IPV (Pentacel), pneumococcal, and rotavirus.
|Preventive Medicine Service
|First vaccine component
|Each additional vaccine component
|First vaccine component
|First vaccine component
With the discussion of childhood vaccines becoming so much more challenging, use of new codes 90460 and 90461 to adequately report and represent the complexity of these services is very important. It is clear with the increase of preventable illness in children that the role of the vaccines is still essential to ensuring the health of our communities, and coding these correctly is important to supporting this effort.
Lisa Jensen, MHBL, FACMPE, CPC, is the manager of external audits for Providence Health Plans in Beaverton, Ore. Ms. Jensen has a master’s in healthcare business leadership and an undergraduate degree in psychology with an emphasis in behavioral modification. She has spent much of the 19 years of her health care career managing teams and educating colleagues on coding, revenue cycle improvement, and compliance. Her health care experiences include physician clinics, group practices, a teaching hospital, health care consulting, and a health plan.
July 1st, 2011
The U.S. Food and Drug Administration (FDA) approved, March 24, the use of Zostavax, a live attenuated virus vaccine, for the prevention of shingles in people 50 to 59 years of age. Zostavax, manufactured by Merck & Co. Inc., is already approved for use in people 60 years of age and older.
Shingles affects approximately 200,000 Americans between the ages of 50 and 59 every year, more commonly in people with weakened immune systems. It is a disease caused by the varicella-zoster virus, which is a virus in the herpes family and the same virus that causes chickenpox (ICD-9-CM code 053.9 Herpes zoster without mention of complication). After an attack of chickenpox, the virus lies dormant in certain nerves in the body, only to reappear in the form of shingles later in life.
“The likelihood of shingles increases with age. The availability of Zostavax to a younger age group provides an additional opportunity to prevent this often painful and debilitating disease” said Karen Midthun, M.D., director of the FDA’s Center for Biologics Evaluation and Research.
Shingles is characterized by a rash of blisters that generally develop in a band on one side of the body. The rash can cause severe pain that may last for weeks–and some people, for months or even years after the episode.
Source: FDA news release
April 1st, 2011