Learn whether Medicare is paying for preventive services, how to bill for meningococcal vaccine, as well as coding for Medicare Advantage plans.
A: Yes. According to the Centers for Medicare and Medicaid Services (CMS), "The Affordable Care Act (ACA) extends the preventive focus of Medicare coverage, which currently pays for a one-time initial preventive physical examination (IPPE or the "Welcome to Medicare Visit"), to provide coverage for annual wellness visits in which beneficiaries will receive personalized prevention plan services (PPPS)."
Specifically, the ACA waives both the deductible and co-insurance for some Medicare-covered preventive services, including the initial preventive physical examination and the new annual wellness visit. The ACA also waives the Part B deductible for tests that begin as colorectal cancer screening tests but, based on findings during the test, become diagnostic or therapeutic services.
CMS has developed two level 2 Healthcare Common Procedure Coding System codes for the annual wellness visits. The first is G0438, Annual wellness visit, including personalized prevention plan services, first visit. This code will be paid at the rate of a level 4 office visit for a new patient (similar to the IPPE). The second is G0439, Annual wellness visit, including personalized prevention plan services, subsequent visit. This code will be paid at the rate of a level 4 office visit for an established patient.
The policy is effective for services provided on or after January 1.
BILLING FOR MENINGOCOCCAL DISEASE VACCINE
Q: The CPT code for the meningo-coccal disease vaccine is 90734. What ICD-9-CM code should I use?
A: As you note, the CPT code for the meningococcal disease vaccine (meningococcal conjugate vaccine, serogroups A, C, Y, and W-135 [tetravalent], for intramuscular use) is 90734. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends this vaccine for those aged 11 to 18 years.
The CPT administration code that should be used-90471, Immunization administration, one vaccine, or 90472, Immunization administration, each additional vaccine-depends on the number of vaccines administered at the visit for which you are billing. Append the following ICD-9-CM code to the vaccine code (90734) and to the appropriate administration code: V03.89, Need for prophylactic vaccination and inoculation against bacterial diseases; other specified vaccinations against single bacterial diseases; other specified vaccination.
Bill using an evaluation and management (E/M) code only if you see the patient for a significant, separately identifiable service. When you bill an E/M code along with the injection, the E/M code must have a 25 modifier appended.
Also, if you are a provider through the Vaccines for Children (VFC) program, it would be appropriate to bill the vaccine code (90734) in addition to the administration code. You will be reimbursed only for the administration of the vaccine, however, because the VFC program offers the vaccine at no charge.
CODING FOR MEDICARE ADVANTAGE PLANS
Q: Where can I check the criteria for coding different hepatocellular carcinoma diagnoses for Medicare Advantage plans?
A: Most such plans follow Medicare guidelines for reimbursement, but they may have different criteria to substantiate a claim. Check with each of your Medicare Advantage plans to learn the diagnosis codes that support medical necessity for the code you are billing.
The author is a medical consultant based in Indianapolis, Indiana. Do you have a primary care-related coding question you would like to have our experts answer in this column? Send it to firstname.lastname@example.org