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Revision of CPT codes
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It’s the start of another new year. Each Jan. 1 signals a new beginning, a chance at a new start. For some, this Jan. 1 is 1 year closer to partnership, for others, it means time to plan for retirement. One certain thing to occur for all of us pediatricians is the advent of change to the CPT codes. There are some deleted, some revised and some new codes.
If you use a deleted code, you won’t be paid; if you use a revised code incorrectly, you might not be paid, and if you neglect to use a new code, well, who knows what will happen?
There have been changes to the vaccine administration codes. Some have been deleted and some are new. The administration codes 90465-90468, which were for patients younger than aged 8 years who received physician counseling, have been deleted. They have been replaced with antigen-based codes. Use 90460 for the first antigen and 90461 for the second and other antigens. These codes are to be used for patients younger than aged 19 years who have received vaccine counseling from a “qualified health professional.”
Although the American Medical Association has offered its definition of a qualified health professional, each state has or should have its own definition. Some states require that a physician perform the counseling, and other states also allow an RN, LPN or CMA to counsel patients. Be sure to check your state’s definition.
The new codes were assigned the same relative value units (RVUs) as the previous codes. For example, the 90460 code is assigned .68 RVU and the 90461 code is .34 RVU. These antigen-based codes reward physicians for the work involved counseling patients regarding vaccines that have more than one antigen. Previously, one vaccine administration code was used for each vaccine given, even if that vaccine involved multiple antigens. For example, measles-mumps-rubella vaccine (CPT 90707) was given one vaccine administration code. However, the MMR vaccine administration codes will now be 90460 for the first antigen and then 90461 repeated twice for the second and third antigen (either repeated or listed as two units). The amount of time spent and work to counsel has not changed; only payment for that work is an improvement for physicians.
Using 2011 CPT codes, when an MMR is given with an inactivate polio vaccine (CPT 90713) list 90460, 90461 (two times) for the MMR and 90460 for the IPV, which has a single antigen. The CPT series 90471-4 is to be utilized for patients who are not counseled by a health care professional or for anyone older than aged 19 years.
These codes should be helpful financially; however, at this time, there is uncertainty regarding how managed care organizations will pay for these new codes. There is also confusion regarding how CMS will have Medicaid programs pay for the new codes. I would urge my colleagues to code correctly, look over your Explanation of Benefits carefully and report problems promptly.
Richard Lander, MD, is a member of the Infectious Diseases in Children Editorial Board. He is in private practice in Livingston, N.J. and is the New Jersey Chairman of the AAP section on Administration and Practice Management; and is a Clinical Assistant Professor of Pediatrics at the University of Medicine and Dentistry of New Jersey.
Disclosure: Dr. Lander is co-owner of the National Discount Vaccine Alliance, is co-owner of Resources in Physician Management Services, and is a speaker for Merck, Sanofi-Pasteur, Novartis and Pfizer.