CODING & DOCUMENTATION

No. Unless a payer requires other codes (as may apply under the Vaccines for Children program), when a physician (not clinical staff) provides and documents counseling for immunizations, you should report codes 90460, “Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid component administered,” and 90461, “each additional vaccine or toxoid administered.” For example, for administration of measles, mumps, and rubella vaccine, you would report code 90460 once for the measles component and code 90461 twice — one time each for the mumps and rubella components. When reporting three separate vaccines, report 90460 three times – one time each for the first/only component of each vaccine and 90461 for each additional component.Code 90472, “Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), each additional vaccine (single or combination vaccine/toxoid),” may be used in conjunction with code 90460 only when a physician provides counseling for one immunization and does not provide counseling for another immunization administered on the same date. This could occur if the patient received counseling on a prior date when an initial dose was administered or an immunization was refused.When no physician counseling is provided on a date when multiple immunizations are provided, report either immunization administration code 90471 or 90473 (depending on the route of administration) for the first vaccine administered and either 90472 or 90474 for each additional vaccine product (not component) administered.Also remember to bill separate vaccine product codes (90476–90749) for each vaccine administered.

Yes, use code 99051, “Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service,” in addition to the evaluation and management or other procedure codes if the health plans most commonly billed by your practice allow payment for this add-on code. More payers are recognizing that care provided by primary care physicians after regular business hours helps avoid costly care provided in urgent care or emergency department settings. Your coder or practice manager should be able to tell you which health plans in your area pay for code 99051 as well as code 99050, “Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday, or Sunday), in addition to basic service.”Many payers post their reimbursement policies online for reference. Note that policies vary and are subject to change periodically. It is also important to note any limitations individual payers may apply to coverage (for example, 99050 may be paid only for nonroutine services).

There are other criteria. The CPT section on chronic care management services states, “Patients who receive chronic care management services have two or more chronic continuous or episodic health conditions that are expected to last at least 12 months, or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.”