Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part two Third-party...
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Transcript of 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
Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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
Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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
Coding 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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
Overview – Coding for Vaccines and Immunization Services– Documentation Guidelines
– CPT® Coding Basics
– ICD-9-CM Coding Basics
– Additional Challenges
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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
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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
14Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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.
15Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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
Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
Immunization Administration cont’d.
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
Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
Immunization Administration cont’d.
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.
Immunization Administration cont’d.
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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
Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
– 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)
19Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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
26Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
Billing Processes cont’d.
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
Billing Processes cont’d.
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
Billing Processes cont’d.
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
Billing Processes cont’d.
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)
Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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Coding and Electronic Billing for Vaccines, August 22, 2012. Webinar Series – Part twoThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments
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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