Receiving queries for H1N1 vaccinations. What are our coding options and restrictions?

Answer: You should now code H1N1 vaccination as you would any other influenza vaccines. According to CDC the H1N1 virus that caused that pandemic is now a regular human flu virus and continues to circulate seasonally worldwide.
You will report most types of flu injections, including a vaccine like the H1N1 shot, using two codes:

• A code for the flu vaccine itself, depending upon the type of vaccine (injectable liquid, intranasal mist, intraoral), whether it’s preservative-free and whether the receiver is a Medicare beneficiary.

o  Use from within 90654-90688 codes for the particular vaccine you may using. Use       from within Q2033-Q2039 for Medicare beneficiaries, when applicable

• A code for the administration of the injection

o  Use 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) for single injection
o  Use 90472 (…each additional vaccine [single or combination vaccine/toxoid]) for subsequent injections
o  Use 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]) for single intranasal or intraoral application
o  Use 90474 (…each additional vaccine [single or combination vaccine/toxoid]) for additional intranasal or intraoral applications

• You will use administration code G0008 for Medicare-only patients (and those that follow Medicare guidelines)

Tip: Make sure you report V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases; influenza) as your diagnosis. Medicare has fixed the payment at same rates as the administration of the seasonal influenza vaccine (G0008, Administration of influenza virus vaccine).

Do I need a pathology report to choose the appropriate code?

Answer: The pathology report will help in choosing the correct ICD/diagnosis code. Whether the report affects your procedure code depends on whether you’re reporting a biopsy or excision. The report will not determine which biopsy code you should choose because biopsy codes don’t differ based on the nature of the lesion.

In most cases, however, the pathology report will help in identifying the appropriate excision code because those codes do differ based on whether the lesion is benign or malignant. For instance, note the term “benign” in 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less).
What questions do you have about reporting biopsy or excision of a skin lesion? Let us know your answer in the comments section below.

Expert Advice Simplifies Coding for Biopsy and Excision of Skin Lesions

Some of the most frequently performed procedures in a dermatology practice are biopsies. However, if you do not know how to differentiate between biopsy and excision, your practice may lose hundreds of dollars per procedure. To keep your claims in the clear, apply our experts’ answers to these common lesion coding questions.

Question:

Question:

Question:

Question:

What are examples of frequently used site-specific skin biopsy codes?

Answer: Here’s a list of some commonly used biopsy codes and their Medicare Physician Fee Schedule rates when performed in a nonfacility setting. These rates are the national rates before applying geographic price adjustments. All the site-specific codes have higher rates than generic codes 11100 ($104.40) and +11101 ($32.89), which you use only when no more specific code is available.

• 11755 — Biopsy of nail unit (e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure) [$134.80]
• 30100 — Biopsy, intranasal[$144.45]
• 40490 — Biopsy of lip[$131.58]
• 40808 — Biopsy, vestibule of mouth[$194.51]
• 54100 — Biopsy of penis; (separate procedure)[$201.30]
• 67810 — Incisional biopsy of eyelid skin including lid margin[$173.05].

Important: Before choosing a biopsy code, remember that you first must determine whether the dermatologist performed a biopsy or excision. Proper identification will ensure your coding and reimbursement are correct. For instance, while 67810 brings in $173 for eyelid biopsy, the rate is $523.09 for excision code 11646 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm).

When do I report a site-specific biopsy code instead of 11100?

Answer:  CPT® code 11100 is not specific for a lesion at a specific location. The code description specifies, “unless otherwise listed,” therefore, use this code only when your dermatologist takes a biopsy from a site for which CPT® doesn’t have a more specific code.

The good news is that site-specific codes represent procedures with higher relative value units (RVUs) on the Medicare Physician Fee Schedule, which means higher payment. Therefore, in addition to coding correctly, there’s a financial benefit to reporting the most specific code for the biopsy site.

How is an excision different from a biopsy?

Answer: If the dermatologist removes a lesion fully, the procedure is called an excision. In cases where he decides to take only a sample to test the pathology of the lesion, he performs a biopsy.

Use CPT® code 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) if the dermatologist decides to take a sample for biopsy. Report each additional lesion biopsy with one unit of CPT® code +11101 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; each separate/additional lesion [List separately in addition to code for primary procedure]).

To report an excision procedure, consider the size of the lesion, location of the lesion, and nature of the lesion (malignant or benign) to decide the appropriate CPT® code. Report a code from the range 11400-11446 (Excision, benign lesion including margins, except skin tag …….) for benign lesions of the skin. Report the appropriate CPT® code from the range 11600-11646 (Excision, malignant lesion including margins…) for malignant skin lesions.

CMS Clears up the Most Common ICD-10 Myths

Plus: MACs to increase minimum dollar amounts for appeals in 2015

You’ve heard there won’t be an ICD-10 book that you can keep on your desk because the abundance of codes would make a book too thick—but is that tale true? Actually, no—it’s one of many ICD-10 myths that CMS hopes to dispel with its latest publication, called ICD-10-CM/PCS Myths and Facts.
Indeed, hard copies of the ICD-10 code book are already available and don’t take up more space than your current coding books, CMS says in the document. If you prefer leafing through a book over checking codes online, you’ll still get to handle business as usual when ICD-10 takes effect next October.

Likewise, CMS dispels the myth that you’ll have to scrap your CPT® knowledge when ICD-10 kicks in, since many providers erroneously believe that ICD-10-PCS will replace CPT®. In actuality, however, ICD-10-PCS will only be used for facility reporting of inpatient procedures, and won’t impact Part B providers’ use of CPT®.

Resource: To read the complete document, visit www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10MythsandFacts.pdf.