Author: Patti Lewis

From flu to tetanus and now COVID-19, vaccines are among the most common outpatient procedures providers administer on a day-to-day basis. But they can also be complex to code and bill, and undetected mistakes can result in continual underpayment for services rendered.

What makes vaccines so tricky? In most instances, coders must consider a range of factors to ensure the procedure is properly coded, and it can be easy to overlook specific details or nuances. This is especially true if multiple injections are given to a single patient during one encounter.

Some of the key variables associated with vaccine coding include:

• Patient age
• Insurance
• Route of administration
• Total number of vaccines given in the same encounter
• Physician counseling
• State vaccines programs

General Vaccine Information

Q-Codes

Vaccine codes are published on a semi-annual basis, typically July 1 and January 1, by the American Medical Association (AMA). Current Procedural Terminology (CPT®) vaccine codes range from 90476 through 90749 with the additional range 91300-91303 added in 2021 to cover the new COVID-19 vaccines. Q-codes are reimbursed at reasonable cost to providers, and Medicare deductible and co-insurance amounts do not apply when the Q-codes are reported to Medicare.

Age-restricted vaccines

While many vaccines don’t have specific age requirements, others can be designated pediatric, adolescent or adult. As a result, it’s important for coders to confirm that the vaccine administered is appropriate for the patient’s age.

Code set administration

In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration. Administration codes encompass three general categories:

• CPT® range 90471 — 90474 identifies vaccines without Counseling (over 18 years of age)
• CPT® range 90460 — 90461 identifies vaccines with Counseling (thru age 18)
• CPT® range 91300 — 91303 identifies COVID-19 vaccines
• HCPCS Codes G0008, G0009 and G0010 are specific to Medicare beneficiaries

State programs

Some physician practices participate in state-sponsored Vaccines for Children (VFC) programs. Because the state generally provides the practice with the vaccines, physicians may not charge beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers.

However, providers may charge patients for the administration fee associated with providing the vaccine. For vaccines provided as part of the VFC program, the CPT® code range is 90476 — 90749, with modifier SL appended in the first reporting modifier field.

Route of administration

Ensuring the correct route of administration allows the coder to select the appropriate administration code. Most vaccines are given as injections and are reported using administration codes 90471 and 90472. But there are a few oral and intra-nasal vaccines that are reported using administration codes 90473 and 90474.

Initial vaccines

If one or more vaccines are administered during an encounter, it is necessary to specify an initial administration code first. Initial administration codes include:

• 90471: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial
• 90473: Immunization administration for intra-nasal or oral route, initial

Only one initial administration code is reported per encounter. If both injectable and oral/intra-nasal vaccines are performed during the same visit, providers should report 90471 as the initial administration code. Codes 90471 – 90472 have a slightly higher reimbursement than oral/intra-nasal administration.

Subsequent vaccines

If more than one vaccine is administered on the same day, a second or third administration code is required to document the additional vaccines. All subsequent vaccine codes (90472 and 90474) are classified as add-on codes and must be reported with an initial administration code. The definitions for subsequent administration codes are:

• 90472: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, each additional vaccine
• 90474: Immunization administration for intra-nasal or oral route, each additional vaccine

When three or more vaccines are performed during an encounter, units should be applied to the administration code for each additional vaccine of the same type (injectable or oral).

Here are some examples:

• Five injectable vaccines: report 90471 X1 unit (initial) and 90472 X4 units (subsequent)
• One intra-nasal and two oral vaccines: 90473 X1 unit (initial) and 90474 X2 units (subsequent)
• Four injectable vaccines and one oral vaccine: 90471 X1 unit (initial) and 90472 X3 units (subsequent) and 90474 X1 unit (subsequent)

Product Vaccine Examples

CPT ®Code	Description
90714	Tetanus and diphtheria toxoids, older than 7
90715	Tetanus, diphtheria toxoids, and acellular pertussis vaccine, older than 7 [NOTE: 90715 should be used for Adacel vaccine as this code describes a tetanus and diphtheria booster vaccine for both adult and adolescent use with the age indication for Adacel being 11-64 years of age.

COVID-19 Vaccine Codes

In response to the COVID-19 pandemic, the FDA has approved vaccines by Pfizer (December 11, 2020) Moderna (December 18, 2020) and Johnson & Johnson (Janssen) (February 27, 2021) for use under an EUA. The AMA has also created CPT code set in the likelihood that the AstraZeneca and University of Oxford is granted EAU approval. The administration code will be reported based on whether it is the first or second dose.

Under the CARES Act, Medicare will provide beneficiaries COVID-19 vaccine administration with no cost-sharing to beneficiaries under Part B coverage. Initially, providers will not incur a cost for the drug because products will be distributed through government agencies. Providers should not bill for the drug when they receive it at no cost. The Centers for Medicare & Medicaid Services (CMS) states it will establish COVID-19 drug product allowances, which will be based on reasonable costs (or, for physician offices, 95% of Average Wholesale Prices), later. Per the Medicare Claims Processing Manual Chapter 32 – Billing Requirements for Special Services section 67.2, providers should not bill for drugs received at no cost.

COVID-19 vaccine product codes

Vaccine Code	CPT Long Descriptor	Mfr Vaccine/Procedure	MCR Allowed	Effective Date
91300*	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19] vaccine, mRNA-LNP, spike protein, preservative free, 20 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use (HFRI-PARA note: Report administration code 0001A or 0002A)	Pfizer-BioNtech Covid-19 Vaccine	$0.01	12/11/2020
91301*	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-10]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use (HFRI-PARA note: Report administration code 0011A or 0012A)	Moderna Covid-19 Vaccine	$0.01	12/18/2020
91302*	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-10]) vaccine, DNA, spoke protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use. (HFRI-PARA note: Report administration code 0021A or 0022A)	AstraZeneca Covid-19 Vaccine	$0.01	TBD
91303	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-10]) vaccine, DNA, spoke protein, adenovirus type 26 (Ad26) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use	Janssen Covid-19 Vaccine	$0.01	2/26/2021

* Initially, providers will not incur a cost for the drug product as they will be distributed through government agencies. Providers should not bill for the drug when they receive it at no cost. CMS will update the payment allowance later.

COVID-19 Vaccine Administration Codes

Effective immediately after the FDA approves vaccinations with an Emergency Use Authorization, providers may report the COVID-19 administration code based on the type of vaccine and which dose is provided.

All providers participating in the CDC COVID-19 Vaccine Program:

• Must provide the vaccine at no cost to the individual (may also balance bill)
• Cannot charge an office visit (or other fees or services) if the individual received only the vaccine
• May not deny vaccine based on insurance coverage or out-of-network status

The Office of the Inspector General encourages reporting potential violations through its tip line 1-800-HHS-TIPS (1-800-447-8477) or website. The following chart shows the vaccine product code with the corresponding administration code(s).

Vaccine and Administrative Codes
Service	Description	Rev Code	Condition(s) Code(s)	Dx Notes	Dosing Info
Pfizer
91300	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)	0636	A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage	Z23 – Encounter for immunization	21 Days
0001A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose	0771
0002A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose	0771
Moderna
91301	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)	0636	A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage	Z23 – Encounter for immunization	21 Days
0011A	Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 100 mcg/0.5mL dosage; first dose	0771
0012A	Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 100 mcg/0.5mL dosage; second dose	0771
Janssen
91303	Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)	0636	A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage	Z23 – Encounter for immunization	Single Dose
0031A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5×1010 viral particles/0.5mL dosage, single dose	0771
AstraZeneca (Currently not approved in the United States)
91302	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)	0636	A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage	Z23 – Encounter for immunization	28 Days
0021A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage; first dose	0771
0022A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5×1010 viral particles/0.5mL dosage; second dose	0771
Novavax (Currently not approved in the United States)
91304	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage, for intramuscular use (DO NOT REPORT IF PROVIDED FREE OF COST)	0636	A6 – 100% Medicare Payment For patients who have Medicare Advantage Plans, bill services to traditional Medicare and report 78 – New coverage not implemented by Medicare Advantage	Z23 – Encounter for immunization	21 Days
0041A	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; first dose	0771
0042A	I Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; second dose	0771

COVID-19 Vaccine Administration Payment Rate Increase

CMS announced on March 15, 2021 that COVID-19 vaccine administration payment rates will increase to $40 each dose (geographically adjusted). The increased rates, which go into effect for dates of service on or after March 15, 2021, are expected to increase the number of vaccines administered daily by helping to establish new or expand current vaccination sites, hire additional staff, and provide community education.

Code	Mfr Vaccine/ Procedure Name	Payment Allowance	Effective Date	Payment Allowance after Date of Service 03/15/2021
0001A	Pfizer BioNtech Covid-19 Vaccine Administration – First Dose	$ 16.94	12/11/2020	$40.00*
0002A	Pfizer BioNtech Covid-19 Vaccine Administration – Second Dose	$ 28.39	12/11/2020	$40.00*
0011A	Moderna Covid-19 Vaccine Administration – First Dose	$ 16.94	12/18/2020	$40.00*
0012A	Moderna Covid-19 Vaccine Administration – Second Dose	$ 28.39	12/18/2020	$40.00*
0031A	Janssen Covid-19 Vaccine Administration	$28.39	02/26/2021	$40.00*
0021A	AstraZeneca Oxford Covid-19 Vaccine Administration – First Dose	$40.00	TBD	TBD
0022A	AstraZeneca Oxford Covid-19 Vaccine Administration – Second Dose	$ 40.00	TBD	TBD
0041A	Novavax Covid-19 Vaccine Administration – First Dose	$40.00	TBD	TBD
0042A	Novavax Covid-19 Vaccine Administration – Second Dose	$40.00	TBD	TBD

Vaccine Administration in the Home

Effective June 8, 2021, Medicare will pay providers currently eligible to bill for COVID-19 vaccine administration (i.e., physicians, pharmacies, non-physician practitioners, and hospitals) an additional $35 per COVID-19 vaccine dose when provided in the patient’s home to a Medicare beneficiary who has is hard-to-reach or has difficulty leaving home. M0201 COVID-19 vaccine home administration may be reported with the COVID-19 administration code when the sole purpose of the healthcare home visit was to administer the vaccine. This add-on payment raises the total provider reimbursement to approximately $75 (which amount includes the $40 reimbursement for the specific vaccine administration.) When a provider administers the COVID-19 vaccine to multiple people in the same home during the same visit, the provider may report M0201 (COVID-19 vaccine home admin) only once but should report all COVID-19 vaccine dose-specific administration codes.

HCPCS	Description	Vaccine/Procedure Name
M0201	COVID-19 vaccine home admin	COVID-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only COVID19 vaccine administration is performed at the patient’s home.

RHCs and FQHCs COVID-19 Vaccine Billing

Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) cannot bill COVID-19 for COVID-19 vaccines on a claim form. If the patient is there for another reason, the RHC or FQHC should exclude the cost of the vaccines. It will be settled on a cost report.

A listing of payment rates by each type of Medicare provider can be found in the Medicare FAQ link.

Medicare Provider	Vaccine Payment	Vaccine Administrative Payment
Hospitals – Outpatient Departments	Reasonable Costs*	Separately payable based on established rate for code. Not subjects to OPPS.
Hospitals – Inpatients	Reasonable Costs*	Separately payable based on established rate for code.
Critical Access Hospitals (CAHs)	101% of Reasonable Costs	101% of Reasonable Costs
Rural Health Centers (RHCs)	Paid through the cost report	Paid through the cost report

Additional Resources

• PARA Healthcare Analytics/ParaRev COVID-19 Coding Resource
• Novitas JH (Medicare MAC) provides billing information for Part B providers.
• First Coast Service Options (Medicare MAC), has a webpage devoted to billing for COVID-19 vaccines and monoclonal antibodies for Part A providers.
• CMS created a resource page to provide COVID-19 vaccine policies and guidance for providers, state programs, and beneficiaries.
• Additional information is available through the following CDC weblink.
• The AMA provides instructions for coding administration of the COVID-19 vaccines through its document.

Keeping it all straight

Staying abreast of the latest coding directives can be a challenge, and it can be doubly so when it comes to vaccines, given all the factors that need to be accounted for to code and bill correctly. That’s why Healthcare Financial Resources Inc. (HFRI) and PARA HealthCare Analytics have partnered to deliver comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

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Hospitals on the front lines of the opioid epidemic have new tools to address the scourge of opioid misuse and addiction, including bundled Medicare reimbursements for holistic treatment services.

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act—signed into law by President Trump in October 2018—represents the federal government’s most ambitious effort yet to combat the opioid crisis. The legislation provides solutions across multiple areas, including prevention, treatment, recovery and enforcement.

On Jan. 1, 2020, a bundled Medicare payment became available to hospitals to support comprehensive treatment of opioid disorders. The new reimbursement opportunity is one of several provisions in the act aimed at mitigating opioid misuse risk among Medicare beneficiaries.

A wave of addiction and overdoses

Addiction rates and overdose deaths attributed to opioids have soared since physicians began prescribing the drugs for pain relief in the 1990s. Currently, an average of 130 Americans die every day from overdoses of all types of opioids, including prescription pain relievers, heroin, and synthetic opioids such as fentanyl.[1] From 1999 to 2017, almost 400,000 people died from opioid overdoses;[2] with the annual death toll during that period rising 8,048 in 1999 to 47,600 in 2017.[3]

According to the National Institute on Drug Abuse, between 20-30% of patients who are prescribed opioids for chronic pain misuse them, and between 8-12% develop an opioid use disorder.[4] In 2017, an estimated 1.7 million Americans suffered from substance use disorders (SUDs) related to prescription opioid pain relievers. Significantly, about 80% of those who use heroin first misused prescription opioids.[5]

Opioid overutilization is a significant issue for Medicare. In 2017, nearly one in three beneficiaries received at least one prescription opioid through Medicare Part D. That equates to about 14.4 million of the total 45.2 million seniors enrolled in Part D.[6] And about 1 in 10 Part D beneficiaries, or 4.9 million people, received opioids for a total of three or more months in 2017.

“Opioids may have been necessary for many of these beneficiaries, but these high numbers raise questions as to whether opioids are being appropriately prescribed and used,” the Department of Health and Human Services’ Office of Inspector General wrote in 2018. “Research shows that the risk of opioid dependence increases substantially for patients receiving opioids continually for 3 months.”[7]

Support Act provisions

The Support Act stipulates that beginning on or after Jan. 1, 2020, Medicare will pay 100% (less any beneficiary co-payments) of a bundled payment for opioid use disorder (OUD) treatment provided to Medicare beneficiaries during an episode of care.

Medicare has not previously offered an explicit OUD benefit, although many services necessary for OUD treatment have been covered under broad Medicare benefit categories.[8] Additionally, the act requires opioid treatment plans to include the administration of medication-assisted treatment (MAT) drugs, individual and group therapy, toxicology testing and other items and services as deemed appropriate by the HHS.[9]

In addition to the new bundled payment, the Support Act includes several other provisions to address opioid risk and abuse within the Medicare population. These include:[10]

1. Expanding the use of telehealth services beyond rural, underserved areas for the treatment of substance use disorders (SUDs), effective in July 2019. Also allows Medicare Advantage plans to provide additional telehealth benefits.
2. Screening for potential SUDs during a beneficiary’s Initial Preventative Physical Examination (IPPE), effective Jan. 1, 2020. This provision also includes review of the beneficiary’s current opioid prescriptions during their annual wellness visit.
3. Starting Jan. 1, 2021, all prescriptions for Part D covered Schedule II, III, IV, or V controlled substances mush be transmitted electronically. Some exceptions apply, however.
4. Part D plans are required by Jan. 1, 2022 to implement lock-in programs for beneficiaries at risk for opioid misuse or abuse. The plans will limit the number of pharmacies and prescribers an at-risk beneficiary can use for their opioid medications.
5. CMS also is directed, no later than Jan. 2, 2021, to conduct a four-year demonstration project on increasing access to OUD treatment, improving beneficiary outcomes and reducing Medicare expenditures.

It is recommended all providers review the tables that contain all provisions and scheduled implementation dates of the Act, as its provisions will impact all providers, including Federally Qualified Health Centers and Rural Health Clinics.

Coding and Claims

Special enrollment for opioid disorder treatment (ODT) programs is required to be eligible for reimbursement. Reimbursement for the program is per week of treatment. Additional professional and facility fee reimbursement is limited only to G2086, G2087 and G2088.

The chart below contains HCPCS and payment rates for weekly ODP Program services. The information is available through CMS.[11]

CY2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F

HCPCS	Descriptor	Drug Cost	Non-Drug Cost	Total Cost
G2067	Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)	$35.28	$172.21	$207.49
G2068	Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare enrolled Opioid Treatment Program)	$172.21	$86.26	$258.47
G2069	Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) (+This code should be billed only during the week that the drug is administered. HCPCS code G2074, which describes a bundle not including the drug, would be billed during any subsequent weeks that at least one non-drug service is furnished until the injection is administered again, at which time HCPCS code G2069 would be billed again for that week.)	$1,578.64	$178.65	$1,757.29
G2070	Medication assisted treatment, buprenorphine (implant insertion); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)	$4,918.98	$407.86	$5,326.84
G2071	Medication assisted treatment, buprenorphine (implant removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)	$0	$427.32	$427.32
G2072	Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)	$4,918.98	$626.97	$5,545.95
G2073	Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program	$1,164.02	$178.65	$1,342.67
G2074	Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)	$0	$161.71	$161.71
G2075	Medication assisted treatment, medication not otherwise specified; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).	–	–	–

Intensity Add-on Codes (+ The medical services described by these add-on codes could be furnished by a program physician, a primary care physician or an authorized healthcare professional under the supervision of program, physician, or qualified personnel such as nurse practitioners and physician assistants. The other assessments, including psychosocial assessments could be furnished by practitioners who are eligible to do so under their state law and scope of licensure.)[12]

Intensity Add-On Codes

HCPCS	Descriptor	Drug Cost	Non-Drug Cost	Total Cost
G2076	Intake activities, including initial medical examination that is a complete, fully documented physical evaluation and initial assessment conducted by a program physician or a primary care physician, or an authorized healthcare professional under the supervision of a program physician or qualified personnel that includes preparation of a treatment plan that includes the patient’s short-term goals and the tasks the patient must perform to complete the short-term goals; the patient’s requirements for education, vocational rehabilitation, and employment; and the medical, psycho- social, economic, legal, or other supportive services that a patient needs, conducted by qualified personnel (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.	$0	$179.46	$179.46
G2077	Periodic assessment; assessing periodically by qualified personnel to determine the most appropriate combination of services and treatment (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.	$0	$110.28	$110.28
G2078	Take-home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare enrolled Opioid Treatment Program); List separately in addition to code for primary procedure. (+ SAMHSA allows a maximum take-home supply of one month of medication; therefore, CMS does not expect the add-on codes describing take-home doses of methadone and oral buprenorphine to be billed more than 3 times in one month (in addition to the weekly bundled payment))	$35.28	$0	$35.28
G2079	Take-home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure. (+ SAMHSA allows a maximum take-home supply of one month of medication; therefore, CMS does not expect the add-on codes describing take-home doses of methadone and oral buprenorphine to be billed more than 3 times in one month (in addition to the weekly bundled payment))	$86.26	$0	$86.26
G2080	Each additional 30 minutes of counseling or group or individual therapy in a week of medication assisted treatment, (provision of the services by a Medicare enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.	$0	$30.94	$30.94

Table notes: Methadone drug costs are calculated using ASP data, oral buprenorphine drug costs are calculated using NADAC data, and the other drug costs are calculated using data from the quarterly ASP Drug Pricing Files. The payment amounts in this table are based on data files posted by CMS. The non-drug component for the non-drug bundle is based on the sum of the rates under Medicare for the following codes: CPT codes 90832, 90853, 80305, and HCPCS codes G0396 and G0480. For the codes that include oral medications (HCPCS codes G2067 and G2068), CMS added to that amount the rate for dispensing oral drugs using an approximation of the average dispensing fees under state Medicaid programs, which is $10.50. For the codes that include injectable drugs (HCPCS codes G2069 and G2073), CMS added to the non-drug bundle amount the fee that Medicare pays for the administration of an injection (which is currently $16.94 under the CY 2019 non-facility Medicare payment rate for CPT code 96372). For the codes that include implantable buprenorphine (HCPCS codes G2070, G2071, and G2072), CMS added the rates under Medicare for the insertion, removal, and insertion/removal of buprenorphine implants (which is $$246.15, $265.61, and $465.26, respectively, based on the CY 2019 non-facility Medicare payment rates for HCPCS codes G0516, G0517 and G0518). The payment rate for HCPCS code G2076 is based on the CY 2019 non-facility Medicare payment rate for CPT code 99204 plus one presumptive toxicology test (CPT code 80305). The non-drug component for HCPCS code G2077 is based on the CY 2019 non-facility Medicare payment rate for CPT code 99214. The payment rate for HCPCS code G2080 is based on the CY 2019 non-facility Medicare payment rate for HCPCS code G2080 when furnished by an NPP. The non-drug component of the bundled payment amounts, and add-on payments will be geographically adjusted based on the PFS GAF.[13]

Level II Codes

Three new HCPCS Level II G codes are added to the Medicare Telehealth Services list for Calendar Year (CY) 2020.[14] These codes describe new bundled services for the treatment of opioid use disorders (OUD).

The new HCPCS Level II codes for reporting the treatment of OUDs, on or after Jan. 1, 2020, are:[15]

HCPCS	Descriptor	MPFS		OPPS
		Non Fae	Fae	APC Status: s
G2086	Office-based treabnent for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month	$413.23	$301.35	$131.35
G2087	Office-based treabnent for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month	$368.48	$293.77	$131.35
G2088	Office-based treabnent for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure)	$70.01	$35.01	(payment packaged)

In November, the American Association of Professional Coders published the following detailed summary of what the new opioid codes cover and what they do not:

What is Covered Under the New G Codes?

HCPCS Level II code G2086 describes the initial month of treatment, including intake activities and development of a treatment plan, assessments to aid in development of the treatment plan to care coordination, individual therapy, group therapy, and counseling.

HCPCS Level II code G2087 describes subsequent months of treatment, including care coordination, individual therapy, group therapy, and counseling.

HCPCS Level II code G2088 is an add-on code that describes additional resources for a patient beyond what is provided in the base codes. “In other words,” CMS states in the PFS final rule, “the add-on code would address extraordinary circumstances that are not contemplated by the bundled code.” The total time spent by the billing professional and the clinical staff furnishing the OUD treatment services must exceed double the minimum amount of service time required to bill the base code for the month.

CMS assumes patients with OUD — described by ICD-10-CM code F11.x Opioid related disorders — will require two individual psychotherapy sessions per month and four group psychotherapy sessions per month; however, CMS states in the PFS final rule, “We understand that based on variability in patient needs, some patients will require more resources, and some fewer.” At least one psychotherapy service must be furnished to bill for G2086 or G2087. Practitioners can bill for additional psychotherapy furnished for the treatment of OUD using add-on code G0288.

Practitioners reporting the OUD bundle must also furnish a separately reportable initiating visit in association with the onset of OUD treatment. The initiating visit should establish the patient/doctor relationship, allow the practitioner to assess the patient to determine clinical appropriateness of medication-assisted treatment (MAT), if applicable, and provide an opportunity to obtain the required patient consent to receive care management services.

The same services that serve as the initiating visit for chronic care management (CCM) and behavioral health integration (BHI) can serve as the initiating visit for the services described by G2086-G2088. The face-to-face visit included in transitional care management services also qualifies as a comprehensive visit.

For new patients, or patients who have not been seen by the practitioner within a year prior to the start of CCM and BHI services, the practitioner must initiate the OUD service during a comprehensive evaluation and management (E/M) visit, annual wellness visit, or initial preventive physical exam. Most of the E/M visit codes are on the Medicare telehealth list and can be furnished in addition to G2086-G2088.

What’s Not Covered Under the New OUD Codes?

The new G codes should not be billed for patients who are receiving treatment at an opioid treatment program (OTP).

If a patient’s treatment involves MAT, this bundled payment does not include payment for the medication itself – billing and payment for medications fall under Medicare Part B or Part D. Payment for medically necessary toxicology testing is billed separately under the Clinical Lab Fee Schedule.

When furnished to treat OUD, CPT® psychotherapy codes 90832, 90834, 90837, and 90853 may not be reported by the same practitioner for the same patient in the same month as G2086, G2087, G2088. Practitioners can bill for additional psychotherapy furnished for the treatment of OUD using +G2088, when medically necessary.

The CPT® psychotherapy codes may be billed concurrently to the G codes for other diagnoses, however. CMS states in the 2020 PFS final rule that practitioners should determine which of the patient’s diagnoses they are treating is primary for the session to determine whether it is appropriate to bill separately for psychotherapy services furnished for co-occurring diagnoses. Hopefully, they will elaborate on the meaning of this statement in future physician education.

Billing the Originating Site Facility Fee

The originating site facility fee may be reported for the face-to-face portions of the services contained in G2086-G2088; however, the geographic limitations for telehealth services furnished on or after July 1, 2019, are statutorily removed for individuals diagnosed with a substance use disorder (SUD) for the purpose of treating the SUD or a co-occurring mental health disorder at any telehealth originating site (other than a renal dialysis facility), including in a patient’s home. Medicare will not pay an originating site facility fee when the individual’s home is the originating site.

The originating site facility fee for telehealth services furnished in CY 2019 was $26.15 and the Medicare Economic Index increase for 2020 is 1.9 percent. Therefore, the CY 2020 payment amount for Q3014 Telehealth originating site facility fee is 80 percent of the lesser of the actual charge, or $26.55.

ParaRev

To learn more about appropriate coding and claims for the new bundled opioid services, contact the coding experts at ParaRev. In addition to providing coding expertise, ParaRev also offers a range of accounts receivable recovery and resolution services and denial management solutions. ParaRev delivers comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement.

1. “Opioid Overdose Crisis,” National Institute on Drug Abuse, January, 2019.
2. “Opioid Overdose: Understanding the Epidemic,” Centers for Disease Control and Prevention, Dec. 19, 2018.
3. “Opioid Death Rates,” National Institute on Drug Abuse, January, 2019.
4. “Opioid Overdose Crisis,” National Institute on Drug Abuse, January, 2019.
5. Ibid
6. “Opioid Use in Medicare Part D Remains Concerning,” U.S. Department of Health and Human Services Office of the Inspector General, June, 2018.
7. Ibid
8. “The SUPPORT for Patients and Communities Act (P.L.115-271): Medicare Provisions,” Congressional Research Service, Jan 2, 2019.
9. “CRS Releases Summary Report on the SUPPORT Act Provisions Affecting Medicare,” Strategic Management Services, February, 2019.
10. “The SUPPORT for Patients and Communities Act (P.L.115-271): Medicare Provisions,” Congressional Research Service, Jan 2, 2019.
11. “CY2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F,” Centers for Medicare and Medicaid Services.
12. Ibid
13. Ibid
14. “List of Telehealth Services,” Covered Telehealth Services CY2019 and CY2020 (Updated 11/1/19), CMS.gov, Nov 20, 2019.
15. Renee Dustman, “New G Codes Bundle Opioid Use Disorder Treatment,” American Academy of Professional Coders, Nov 25, 2019.

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From flu to tetanus, vaccines are among the most common outpatient procedures providers administer on a day-to-day basis. But they can also be complex to code and bill, and undetected mistakes can result in continual underpayment for services rendered.

What makes vaccines so tricky? In most instances, coders must consider a range of factors to ensure the procedure is properly coded, and it can be easy to overlook specific details or nuances. This is especially true if multiple injections are given to a single patient during one encounter.

Some of the key variables associated with vaccine coding include:

• Patient age
• Insurance
• Route of administration
• Total number of vaccines given in the same encounter
• Physician counseling
• State vaccines programs

Q-Codes

Vaccine codes are published on a semi-annual basis, typically July 1 and January 1, by the American Medical Association (AMA). CPT® vaccine codes range from 90476 through 90749. In recent years, Medicare has created additional Q-codes for vaccines. Q-codes are reimbursed at reasonable cost to providers, and Medicare deductible and co-insurance amounts do not apply when the Q-codes are reported to Medicare.

Age-restricted vaccines

While many vaccines don’t have specific age requirements, others can be designated pediatric, adolescent or adult. As a result, it’s important for coders to confirm that the vaccine administered is appropriate for the patient’s age.

Code set administration

In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration. Administration codes encompass three general categories:

• CPT® range 90471 — 90474 identifies vaccines without Counseling (over 18 years of age)
• CPT® range 90460 — 90461 identifies vaccines with Counseling (thru age 18)
• HCPCS Codes G0008, G0009 and G0010 are specific to Medicare beneficiaries

State programs

Some physician practices participate in state-sponsored Vaccines for Children (VFC) programs. Because the state generally provides the practice with the vaccines, physicians may not charge beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers.

However, providers may charge patients for the administration fee associated with providing the vaccine. For vaccines provided as part of the VFC program, the CPT® code range is 90476 — 90749, with modifier SL appended in the first reporting modifier field.

Route of administration

Ensuring the correct route of administration allows the coder to select the appropriate administration code. Most vaccines are given as injections and are reported using administration codes 90471 and 90472. But there are a few oral and intra-nasal vaccines that are reported using administration codes 90473 and 90474.

Initial vaccines

If one or more vaccines are administered during an encounter, it is necessary to specify an initial administration code first. Initial administration codes include:

• 90471: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial
• 90473: Immunization administration for intra-nasal or oral route, initial

Only one initial administration code is reported per encounter. If both injectable and oral/intra-nasal vaccines are performed during the same visit, providers should report 90471 as the initial administration code. Codes 90471 – 90472 have a slightly higher reimbursement than oral/intra-nasal administration.

Subsequent vaccines

If more than one vaccine is administered on the same day, a second or third administration code is required to document the additional vaccines. All subsequent vaccine codes (90472 and 90474) are classified as add-on codes and must be reported with an initial administration code. The definitions for subsequent administration codes are:

• 90472: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, each additional vaccine
• 90474: Immunization administration for intra-nasal or oral route, each additional vaccine

When three or more vaccines are performed during an encounter, units should be applied to the administration code for each additional vaccine of the same type (injectable or oral).

Here are some examples:

• Five injectable vaccines: report 90471 X1 unit (initial) and 90472 X4 units (subsequent)
• One intra-nasal and two oral vaccines: 90473 X1 unit (initial) and 90474 X2 units (subsequent)
• Four injectable vaccines and one oral vaccine: 90471 X1 unit (initial) and 90472 X3 units (subsequent) and 90474 X1 unit (subsequent)

Keeping it all straight

Staying abreast of the latest coding directives can be a challenge, and it can be doubly so when it comes to vaccines, given all the factors that need to be accounted for to code and bill correctly. ParaRev delivers comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

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