Improve Accuracy & Boost Pay-up with New COVID Vaccine Codes

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Improve Accuracy & Boost Pay-up with New COVID Vaccine Codes

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Coding for COVID-19 Vaccines

The American Medical Association (AMA) recently issued 11 new Current Procedural Terminology (CPT) codes to help make your coding for COVID-19 vaccines more accurate – and hopefully improve your reimbursement.

So if your practice is administering vaccines under the Centers for Disease Control and Prevention’s (CDC) COVID-19 Vaccination Program — the only way to legally dispense them — it’s vitally important to master these new codes. Failing to do so could delay your reimbursement, and result in denied claims or in extreme cases, an audit.

Ch-ch-ch-changes!

On Sept. 3, the AMA issued eight new Category I codes to address changes in the formulation and use of COVID vaccines. They are as follows:

  • 91305, 0051A, 0052A and 0053A: These codes are used to identify Pfizer’s modified formulation, which uses a tris-sucrose buffer rather than the original phosphate buffer. The first one addresses the formula itself, while the remaining three denote whether it’s the first, second or third dose.
  • 0004A and 0054A: These refer to both formulations of Pfizer’s booster shots.
  • 91306 and 0064A: These CPT codes apply to Moderna’s booster shot. The first covers the formula while the second is for administration.

To add fuel to the fire, the AMA posted three new CPT codes on Oct. 6 to cover the vaccination of children ages 5 to 11. Code 91307 is for the formula — which is slightly modified from Pfizer’s adult version and administered at a lower dose — while codes 0071A and 0072A apply to the first and second dose respectively.

What Am I Supposed to Do?

First thing’s first: don’t panic. Some of these codes aren’t even active yet; they’re placeholders for when the FDA grants emergency usage or full-fledged approval. For example, none of the pediatric codes are active as of this writing because Pfizer is still submitting the supporting data to the FDA for review. None of those codes are expected to be active before Nov. 1 at the earliest.  Pfizer’s booster shots have been approved for certain populations of your patients.

That said, there are some important details to bear in mind about the process of actually coding for COVID-19 vaccines to ensure you get reimbursed.

Correctly Implement New Codes

In a guidance document outlining proper procedures for applying the new process for coding for COVID-19 vaccines, the AMA specified that you can’t mix and match coding between COVID vaccines or doses. While this wouldn’t result in upcoding or under coding, as the reimbursement rate is consistent regardless of the dose or formulation, the resulting confusion could delay your reimbursement or cause it to be denied altogether.

Example 1:
If one of your practice’s physicians administers doses of Pfizer’s new vaccine formula — codes 0051A, 0052A and 0053A — the formulation code has to correspond. It has to be 91305, rather than code 91300, which refers to Pfizer’s old vaccine formula.

Example 2:
If a physician gives a patient a Moderna booster shot, the formula code has to be the booster code — 91306 — rather than the existing inoculation formula code 91301. Similarly, the booster administration code — 0064A — can only be used in conjunction with 91306.

Example 3:
When a physician delivers either a first or second dose (0071A and 0072A, respectively) of the pediatric version of Pfizer’s vaccine, the formula code has to be 91307, as that is the child-specific formulation.

Clear Documentation Is Key

Proper billing may end when you get paid, but to get you must have strong documentation. Be sure to train your staff on the coding for COVID-19 vaccines utilizing these new CPT codes and the AMA’s hardline approach to them to solid documentation for the services provided. Some key points to remember when documenting vaccines:

  • What vaccine was administered;
  • What formulation of that vaccine was used; and
  • What dose was given.

When coding for COVID-19 vaccines you not only need to accurate utilize the new CPT codes, must also master a variety of new COVID diagnosis codes implemented Oct 1st.  For more information on how to utilize these new ICD-10-CM codes, check out this immediately available online training:: “Oct. 1st Deadline: New 2022 ICD-10-CM Code Changes.” This 60-minute course is hosted by expert coder and educator ­­­­­­­­­­­­­­­­­­­­Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC. Kim walks you through the more than 200 changes to the 2022 edition of ICD-10-CM, all of which took effect Oct. 1. Sign up for this valuable course today!

Note: Healthcare Practice Advisor, a weekly e-newsletter published by Healthcare Training leader, will publish a follow up to this article to walk you through coding for COVID-19 vaccines when the patient also receives a flu shot during the same office visit. You can sign up to receive your free weekly copy of Healthcare Practice Advisor online.


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