2018 Coding Updates: Vaccines, Consult Codes

Q: Are there new vaccine codes for 2018 yet?

A:  Yes - per Medicare after Jan. 1, 2018, they will cover the new influenza virus vaccine code 90756 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use).

During the interim period of Aug. 1, 2017, through Dec. 31, 2017, Medicare Administrative Contractors (MACs) will use code Q2039 (Influenza virus vaccine, not otherwise specified) to handle bills for this new influenza virus vaccine product (Influenza virus vaccine, quadrivalent (ccIIV4). Q2039 is already an active code.

The new influenza virus vaccine code 90756 will then be implemented for DOS on or after Jan. 1, 2018.

Q: I heard that there were new federal documentation guidelines coming out. Is that true?

Answer: It just may be true. In the 2018 Physician Fee Schedule Proposed Rule, Medicare commented that the current evaluation and management (E&M) documentation guidelines create an administrative burden and increased audit risk for providers.

They went on to say that the 1995 and 1997 guidelines may be outdated, and in particular, the history and exam areas create an unnecessary burden. Their intention is to initiate a multi-year process to revise the current guidelines. They are also seeking input from 'all stakeholders' as to the advisability of removing the guidelines or 'counting' of history and exam elements from all levels of E&M services.

The revised guidance would focus on medical decision-making and time as the key indicators for a give level of service. This resembles the last comments made by CMS about finalizing E&M guidelines back in 1999, when they were to have come up with a 'weighted' system that valued decision-making more than the other E&M components.

It looks like they are finally moving in this direction, a long-overdue relief for physicians. But as indicated, this will likely take several years to accomplish - so in the meantime, keep those details coming in the history of present illness (HPI) and exam.

Q:  Have the consult codes finally been eliminated for all payers?

A: No, they will appear in the 2018 CPT manual. But one of the larger commercial payers, United Healthcare, has announced that they will stop paying for consult codes effective Oct. 1, 2017. So you might expect more movement in this direction from the commercial payer community.

Q:  My office manager tells me that I have been receiving denials for critical care services provided to patients in the ICU setting. In every case, I provided documentation that I spent at least 30 minutes providing critical care. How can they only reimburse me for a 99233 or even a 99232?

A: We have been seeing more of this recently. Perhaps the first element of documentation that an auditor would look for relative to critical care service is documentation of the time spent. It is a timed code, and without the time documented you don't qualify. But that is not the only requirement: these codes are also about the actual clinical status of the patient.

Although some reviewers have long confined their review of these types of services to the more mechanical elements such as time, we have seen in increase in the assessment for medical necessity.

Part of this might be explained by the tendency of some providers to code critical care codes for all patients in a certain setting or hospital location. Do you code all patients in the ICU critical care every day? Sometimes patients are there post-operatively as a precautionary measure, but they don't meet the definition of critical care.

Remember that the definition of critical care says that, "a critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition."

If a payer is down-coding you to a 99233, or even a 99232, in spite of a time statement, it is highly likely that they cannot see that that patient meets this definition or level of acuity. In the absence of problems whose status is obviously life threatening, you should make a statement that directly addresses the high risk life-threatening nature of the situation. If this resonates at all with the rest of the note - you shouldn't have this problem anymore.