Coding News and Updates

10/10/2023

AMA Establishes Two Nirsevimab Administration Codes 

Effective October 6, 2023: The American Medical Association has established 2 new Category I Current Procedural Terminology^® codes to identify administration of the nirsevimab respiratory syncytial virus (RSV) monoclonal antibody (ie, 90380, 90381) for passive immunization of immune globulin against contracting RSV with counseling by a physician or other qualified health care professional (QHP) (96380) and without counseling by a physician or other QHP (96381). Report either 96380 or 96381 in lieu of 96372 for administration of nirsevimab on and after October 6, 2023.

96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional

96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection

Be aware that National Correct Coding Initiative edits may be updated to bundle codes 96380 and 96381 when reported in conjunction with preventive medicine or problem-oriented evaluation and management (E/M) service codes (as is the case for immunization administration codes 90460–90461 and 90471–90474). When payer edits bundle immunization and E/M codes, append modifier 25 to the code for a significant and separately identifiable E/M service. Do not report an E/M code for the typical pre- and post-service work of immunization or for addressing a minor problem that required an insignificant amount of time or work by the reporting physician or other QHP.

 Billing office staff should be vigilant for denial of 96380 and 96381, which may occur due to delays in updates to payers’ claims adjudication systems, and monitor payer communications or contact individual payers for instructions on whether claims will be automatically adjusted to allow payment after the system is updated or will need to be resubmitted or appealed. In the past, some payers have automatically reprocessed claims denied due to delayed system updates or system errors, but, even so, it may be necessary to verify that all claims are paid in a timely manner. It is not recommended to withhold billing pending a payer’s system updates, as timely filing policies may still apply.

For additional details, please visit the American Academy of Pediatrics “Nirsevimab Coding & Payment” page.

 3/16/2023

AMA Issues Errata and Technical Corrections for CPT 2023

• Additions to the Evaluation and Management Guidelines
• A test that is ordered and independently interpreted may count both as a test ordered and interpreted.
• For the purpose of documents reviewed, documents from an appropriate source may be counted. (This includes professionals such as teachers, case managers, or attorneys.)
• Corrected the time table for prolonged service reported in conjunction with outpatient consultation code 99245 to indicate that at least 85 minutes of total time, not 80 as previously included, are required to report 99245 and 99417 x 2 units.
• Corrections in Appendix Q, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) Vaccines:
• The dosing interval between dose 2 and dose 3 of Pfizer-BioNTech COVID-19 Vaccine/Comirnaty (91300) is corrected from 180 or more days to “(CDC recommended population[s] [eg, immunocompromised]): 28 or more days.”
• The National Drug Code referenced for code 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) is changed from 80777-0279-07 to 80777-0279-05.

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).

Learn More

7/6/2022

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. 

Learn more 

11/29/2021

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. 

9/3/2021

AMA Updates 2021 E/M Guideline 

The AMA released an Errata and Technical Correction update on September 3. View the file here. 

12/4/2020

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.