American College of Physicians: Internal Medicine — Doctors for Adults ®


Get paid for zoster vaccines; coding for the 'medically unlikely'

Also, get an early look at the Physician Quality Reporting Initiative

From the March ACP Observer, copyright 2007 by the American College of Physicians.

Coding for Part D vaccines

The FDA approved the first live VZV vaccine (brand name Zostavax) in May 2006. The vaccine was covered under most Medicare Part D drug plans but, when I first reported on this issue in September, physicians had no mechanism to bill for its administration. The Tax Relief and Health Care Act of 2006, passed in December, rectified that discrepancy. (See complete coverage online.) The legislation avoided a projected cut in Medicare physician payments, and also mandated payment for the administration of Part D vaccines.

Q: How do I code for the administration of Part D vaccines?

A: The CMS announced the creation of a new Healthcare Common Procedure Coding System (HCPCS) code to be used for this purpose. The new code is: G0377-Administration of vaccine for Part D drug.

Q: How much will I be paid for this service?

A: The national payment for G0377 is $19.33, which is the same as for the administration of influenza, pneumococcal and hepatitis vaccines (G0008-G0010). Reimbursement for all physician services varies by geographic location.

Q: Should I use this code for the administration of all vaccines not covered by Part B?

A: No. Only the administration of vaccines covered by a patient's Part D drug plan may be reported using this code. There are a wide variety of Part D drug plans, all with different formularies. It will be important for the physician to ensure that the vaccine is covered by the patient's particular plan before using this code. Vaccines that were previously paid under Part B should be coded in the same way as in the past.

One other thing to keep in mind is that this is all likely to change in 2008, because the legislation requires that the payment for the administration of Part D vaccines come from Part D from that year forward. How that will be accomplished is unknown at this point and under discussion with CMS.

Coding the 'impossible'

Q: I have heard about Medically Unlikely Edits (MUE). How are these different from CCI edits?

A: The first phase of Medically Unlikely Edits (MUEs) took effect on Jan. 1. The new coding edits were referred to as Medically Unbelievable Edits when they were first proposed for implementation in 2005. Coding edits prevent physicians from billing for certain combinations of services.

Medicare has used other edits, referred to as Correct Coding Initiative (CCI) edits, for many years. There are two significant differences between CCI edits and MUEs. CCI edits are generally designed to prevent physicians from billing for services that are contrary to payment policy, such as billing for two services that are mutually exclusive or billing for a service that is bundled into another. CCI edits also generally may be overridden, when appropriate, through the use of a modifier on the claim.

MUEs are intended to prevent physicians from billing for services that are impossible or nearly impossible to perform. For example, an MUE may prevent a physician from billing for the amputation of three legs on a single patient on the same day. The intent of these edits is to prevent gross fraud and obvious mistakes. Because CMS believes that these services can never be performed, it has not allowed for edits to be overridden through the use of a modifier. CMS has stated that it will allow for an appeals process in cases where physicians have completed this unlikely work.

Keep in mind that an MUE review is one possible reason for Medicare to deny claims. CMS is scheduled to release more MUEs in the near future. There should be little impact on most internists because evaluation and management services are not significantly affected.

Other issues

Q: What are CPT Category II codes?

A: CPT Category II codes are used to define performance measures. The codes are found at the back of the CPT book and are in the format of four digits followed by a letter. For example, a physician would use the code 1000F to code that tobacco use was assessed. Very few physicians are using these codes at this time, but that may change soon.

In July 2007, physicians will become eligible to participate in a program called the Physician Quality Reporting Initiative. This program, which will be covered in more detail in later columns, creates a bonus payment for physicians for reporting quality measures using either specific Category II codes or CMS-created G codes. As you open up the new CPT book, it would be wise to at least take a look at these codes and see what kind of data could be submitted in pay-for-reporting programs in the future.

Q: I changed groups and some of my patients have begun seeing me at my new practice. Can I bill these patients using the new patient office visit codes?

A: Generally, no. In order for a physician to bill for a new patient office visit code, the patient must not have received professional services from that physician within the past three years, even if that physician has changed professional groups. If the patient has not visited your old office in the past three years, then you may bill for a new patient office visit.

Brian Whitman is Senior Analyst for Regulatory and Insurer Affairs in ACP's Washington office.


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