Newly Implemented Codes for Detecting and Protecting Against Orthopoxvirus
On July 26, 2022, three new procedure codes were released and implemented immediately for describing testing and vaccines protecting against orthopoxvirus (eg, monkeypox, vaccinia virus).
•87593 Infectious agent detection by nucleic acid (DNA or RNA); orthopoxvirus (e.g., monkeypox virus, cowpox virus, vaccinia virus), amplified probe technique, each
•90611 Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use
•90622 Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use
Administrations of the vaccines represented by codes 90611 and 90622 are reported using existing vaccine administration codes (90460–90461, 90471–90472).
AMA Posts 2023 Guidelines and Code Revisions
The AMA has released the 2023 CPT guidelines and code revisions online ahead of the official publication of CPT 2023. The AAP Pediatric Coding Newsletter will continue providing articles related to the changes to E/M codes and guidelines throughout 2022.
AMA Updates CPT Code Set To Include Moderna Pediatric COVID-19 Vaccine
On May 19, 2022, the American Medical Association (AMA) announced an editorial update to Current Procedural Terminology (CPT) that includes new product and administration codes assigned to the Moderna COVID-19 vaccine for children 6 months through 5 years old.
The provisional codes are effective for use on the condition that Moderna's vaccine candidate is granted an Emergency Use Authorization (EUA) by the U.S. Food and Drug Administration (FDA).
91311 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use
0111A 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, 25 mcg/0.25 mL dosage; first dose
0112A 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, 25 mcg/0.25 mL dosage; second dose
NCHS Releases New COVID-Related Codes
On April 1, 2022, the National Center for Health Statistics (NCHS) released new International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) codes as follows:
New subcategory: Z28.31 Underimmunization for COVID-19 status
NOTE: These codes should not be used for individuals who are not eligible for the COVID-19 vaccines, as determined by the health care provider.
New code: Z28.310 Unvaccinated for COVID-19
New code: Z28.311 Partially vaccinated for COVID-19
New code: Z28.39 Other underimmunization status
Delinquent immunization status
Lapsed immunization schedule status
Update to December Issue
An update has been made to “Your Questions Answered: Evaluation and Management Coding” in the December 2021 issue.
View the update here.
Coding Edit Needed in Some Cases
Some payers have implemented a coding edit that will require that an appropriate modifier is appended to receive separate payment for Evaluation and Management (E/M) services (eg, 99213, 99393) when billed with COVID-19 immunization administration. Based on coding logic for other immunization administration services, modifier 25 on the E/M would be used only to indicate a significant, separately identifiable E/M service on the same day as another service, such as COVID-19 immunization administration.
See the UHC Smart Edit CVEDN here.
New Janssen Booster Code Released
On October 29, a new code was released for the booster dose of the Janssen vaccine. Read more here.
AMA Updates 2021 E/M Guideline
The AMA released an Errata and Technical Correction update on September 3. View the file here.
Update to the April 2021 AAP Pediatric Coding Newsletter
An update has been made to an example presented in the article “Coding for Adolescent Substance Use Screening.” The updated paragraph appears below.
The pediatrician reports codes 99394 and 96160 linked to diagnosis code Z00.129 (encounter for routine child health examination without abnormal findings). If abnormal findings are noted during the preventive medicine service, the physician reports code Z00.121 (encounter for routine child health examination with abnormal findings) and another code to report the abnormal findings. If the payer requires it, also link code 96160 to diagnosis code Z13.39 (encounter for screening examination for other mental health and behavioral disorders).
Update to the February 2021 AAP Pediatric Coding Newsletter
The February 2021 article “Tips: Office Evaluation and Management Documentation” included the following tip for documenting time-based office and other outpatient evaluation and management services.
Time must be documented for time-based services. When selecting office E/M service codes based on time, documentation must include the total time spent by the physician or other qualified health care professional (QHP) on the date of the encounter as well as description of the activities directed to the individual patient during that time (eg, reviewing history, performing examination, counseling, ordering tests, completing documentation, coordinating care by other health care professionals). Do not include time spent by clinical staff or other QHPs who may not report E/M services. Please do note that third-party payers may have additional criteria regarding the acceptable level of documentation detail and should be contacted for their specifications, including delineations of both face-to-face and non-face-to-face time.
This tip may be seen as implying that more than typical encounter documentation of the service provided and statement of total time spent on the date of the encounter are required. This was not the intent of the tip referenced above, please see the revised tip below.
Time must be documented for time-based services. When selecting office E/M service codes based on time, documentation must include the total time spent by the physician or other qualified health care professional (QHP) on the date of the encounter. For instance, after the basic encounter has been documented (history, examination, tests ordered, data reviewed, and assessment and plan), the total physician time spent on the date of the encounter is added to the documentation. This may be a statement such as “My total time directed to this patient today was 25 minutes.” or may be a time field completed within the electronic health record. Do not include time spent by clinical staff or other QHPs who may not report E/M services.
Update to the December 2020 AAP Pediatric Coding Newsletter
An update has been made to the article “2021 Office Evaluation and Management Questions Answered.” The answer to question 2 under “Questions About Medical Decision-making” has been revised and appears below.
No. The instructions for MDM selection state, “Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter.” Each unique test, as described by a single CPT code, is counted once toward the amount and/or complexity of data to be reviewed and analyzed. However, count each review of a unique test result toward the required combination of data to meet Category 1 in the CPT level of MDM table. Do not count tests that you perform and separately report in determining your level of MDM (ie, count only tests performed by an external source). Separately report each test performed with the appropriate CPT code; choosing to not report a test code to increase your level of MDM would be inappropriate.
Updates to the AAP Pediatric Coding Newsletter
Multiple updates have been made to AAP Pediatric Coding Newsletter issues published between January 2020 and November 2020. Please click here to view them in their entirety.
Updates to AAP Coding Products
Multiple updates have been made to Coding for Pediatrics 2021, Pediatric Office-Based Evaluation and Management Coding: 2021 Revisions, and Pediatric Evaluation and Management: Coding Quick Reference Card 2021. Please click on each publication title to view updates.
New ICD-10 Codes Related to COVID-19 Released
As a result of the ongoing public health emergency, International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) broke from its regular release schedule to release 6 new codes related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)/coronavirus disease 2019 (COVID-19). The following codes go into effect on January 1, 2021:
- Contact with and (suspected) exposure to COVID-19 (Z20.822)
- Encounter for screening for COVID-19 (Z11.52)
- Personal history of COVID-19 (Z86.16)
- Multisystem inflammatory syndrome (MIS) (M35.81)
- Other specified systemic involvement of connective tissue (M35.89)
- Pneumonia due to COVID-19 (J12.82)
For more details on how to report these codes, please refer to https://downloads.aap.org/AAP/PDF/COVID%202020.pdf.
The official ICD-10-CM release can be found at https://www.cdc.gov/nchs/data/icd/Announcement-New-ICD-code-for-coronavirus-19-508.pdf.
Important: A Change Affecting Coding for Many Evaluation and Management Services
Please note this important correction to previously published information regarding code changes for 2021.
Our editors have been advised that under the Current Procedural Terminology (CPT®) 2021 guidelines for all evaluation and management (E/M) services, the order or review of tests that are performed during an encounter and separately reported by the physician or other qualified health care professional are not counted in determination of the level of medical decision-making (MDM) for the E/M service.
The American Medical Association has further clarified that this guideline applies to any test or study for which a separate CPT code may be reported, including laboratory tests. Previous understanding was that if a test or service was valued to include physician work, the ordering and reviewing were already counted under the specific code that would be reported for the interpretation and report. To also count this toward MDM would be double-dipping. Previous understanding was that those services without physician work (eg, laboratory tests, assessments using a standardized instrument) should be counted in determining the level of MDM for services in 2021. American Academy of Pediatrics (AAP) publication errata related to this change will be posted to the websites for AAP Pediatric Coding Newsletter™ (https://publications.aap.org/codingnews), Coding for Pediatrics 2021 (www.aap.org/cfp), and AAP Publishing Errata (www.aap.org/errata).
What does this mean for you?
For any E/M service provided in 2021 for which code selection includes determining a level of MDM (eg, consultations, office visits), you will not count the order and/or review of tests that you perform and can separately report in the determination of the level of MDM. This pertains to E/M codes that are selected based on meeting 2 or 3 of the 3 key components (ie, history, examination, and MDM) or the level of MDM alone (ie, 99202–99205, 99212–99215). Always separately report the code for tests performed in conjunction with an E/M service, when applicable. It would be inappropriate to choose not to report the code for a test and instead count the test toward the level of MDM to increase the level of E/M service reported.
Please disregard any current or previously published information that indicates tests performed during the encounter may be included in the determination of the level of MDM.
Where can I find the official guidelines?
In your 2021 CPT reference, look to the Evaluation and Management Guidelines section titled “Guidelines Common to All E/M Services” and the subsection titled “Services Reported Separately.” This subsection includes the following guidance: “The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code.”
The AAP is here to help!
If you have additional questions about this information, please contact the AAP Coding Hotline by submitting the contact form here.
Did COVID-19 Reveal Your Practice Needs a Checkup?
The COVID-19 pandemic has had a lasting effect on many physicians. With all that has taken place, how is your practice's financial health? Click here for strategies to evaluate its impact on your practice.
A list of available AAP resources related to COVID-19 has been added to the Coding Resources section of this site.
COVID-19 Coding Webinar Available
A new AAP webinar titled "Coding During the COVID-19 Pandemic" is now available and can be accessed free of charge. The webinar addresses navigating rapidly evolving ICD-10-CM and CPT coding for telemedicine, telehealth, and COVID-19 diagnoses and procedures in this unprecedented time.
View the webinar at https://youtu.be/aGeyBlX5p-Q
Coding for COVID-19
The introduction of COVID-19 into the United States has produced an influx of patients into the health care system. While knowing how to diagnose and treat these patients is vital, being able to appropriately code this information for data tracking and payment is also important.
The American Academy of Pediatrics is here to support you as you implement new policies and practices. Please click here for the AAP's continuously updated COVID-19 coding information.
Correction: September 2020 Issue
We have made a correction in "Office E/M 2021: Level 3 Visits" in the September 2020 edition of the AAP Pediatric Coding Newsletter. The examples of risk in the Low-Complexity Medical Decision-making table have been corrected. To view the updated article, click here.
An Important Acronym: RBRVS
The Resource-Based Relative Value Scale (RBRVS) is the Medicare physician fee schedule. Even though the typical Medicare beneficiary is not a child, 77% of public and private payers, including Medicaid programs, have adopted components of Medicare RBRVS to pay physicians, while others are exploring its implementation.
The RBRVS Brochure has been a mainstay of online educational resources for more than 20 years, yet it has not always been easy to find on the American Academy of Pediatrics website. We recently made it more discoverable by posting it on its own landing page, along with its supplemental RBRVS Conversion Spreadsheet. You can find it here.
Correction: "You Code It! Focus on Medical Decision-making"
We have made a correction to Table 3 in the article "You Code It! Focus on Medical Decision-making" in the September 2019 edition of the AAP Pediatric Coding Newsletter. Two points were incorrectly entered for a decision to obtain old records and/or obtain history from someone other than the patient. Only one point should be entered in that row. This did not affect the related "You Code It! Answers: Focus on Medical Decision-making." To view the corrected article, click here.
Correction: "Flu Season 2019-2020: Is Your Coding Prepared?"
We have made two corrections to Table 1 in the article "Flu Season 2019-2020: Is Your Coding Prepared?" in the August 2019 edition of the AAP Pediatric Coding Newsletter. Under code 90672, the manufacturer of FluMist Quadrivalent has been updated to AstraZeneca. Under code 90682, the brand Flublok has been updated to Flublok Quadrivalent. To view the corrected article, click here.
Correction: March 2019 You Code It! Scenario
We have made a correction to Table 1 in the article "You Code It! Answers: What's Wrong with These Claims?" in the March 2019 edition of the AAP Pediatric Coding Newsletter. Code 90461 has been removed from the table and a second unit of 90460 has been added. To view the corrected article, click here.