Below is the transcript from our On-Demand Micro-Webinar:
Vaccine Coding Challenges
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Laura: Good day, welcome, and thanks for joining us. Today we’d like to help you by providing a quick brush up on vaccine coding. I’m Laura, Clinical Informatics Pharmacist for RJ Health, and joining me today is Chris Webb who is our Director, Product Development.
Laura: We chose to discuss vaccines because of sure signs of flu season. The days are getting shorter, and the FDA released the 2018/2019 lots of flu vaccine, so hopefully, you’ve gone out and gotten your flu shot. While coding issues begin with the vaccine for influenza, we’ll also be discussing issues that are common to all vaccine administration. So Chris let’s start with why vaccine coding can be a challenge? How many HCPCS or CPT Codes for vaccines are there?
Chris: Over the last five years we have mapped over 520 vaccine NDCs to over to over 130 vaccine billing codes. Several of these codes cover just this year’s flu vaccines alone.
Laura: Given all those codes and vaccines over those years, how often do these codes change?
Chris: Codes for flu vaccines are updated every year due to new code approval process. Many of these changes can occur in general. However, the vaccines could be on the market beforehand. Even so, if you are familiar with the billing requirements for the season, they can change mid-season.
Laura: What are the high-level challenges that are involved in billing or payment for vaccines?
Chris: Each payer may have additional requirements such as specific diagnostic or administration codes on the claim. Billing requirements may also vary depending on the site of care and type of coverage the patient has. So it’s important to understand the individual requirements of a payer in addition to the challenges inherent to the coding system alone.
Laura: While payer requirements are really beyond the scope of the review that we are doing today we can assist with some more specific coding level challenges which we’ll go into in the next slide. So Chris, what code issues will we be discussing today?
Chris: When we are dealing with code level data, important basics include the billing of the correct units and making sure that you are billing under the correct code. These may seem pretty simple at first. For example, you would use the code 90685 to bill a quadrivalent vaccine, one that covers four strains of influenza; then the description becomes more specific for the available product. For this code to apply, the vaccine would also need to be preservative free and given via an IM route. Only two NDCs mapped to this particular code.
For this year, seven brands of quadrivalent vaccines are available, but due to different properties including dose, 28 individual NDCs crosswalked back to 9 different codes. The billing units can also differ from one code to the next. Dosing for flu vaccines ranges from 0.25mls to 1 dose depending on the code. Also, the dosing to billing unit conversion may not always be listed in the code description as it is here. Additionally, with NDC mandates applied correct NDC units may be required on the claim as well. Moreover, NDC units will not always match the dose or codes.
Laura: Chris, while we are on the topic of units can you discuss some of the challenges specific to selecting the correct units, and how that will affect pricing on a claim based on those units? Because it seems that selecting code units for a vaccine would be easy, billing units are easy for one because one dose is given, and reimbursement for one unit service is pretty straightforward, isn’t it?
Chris: That’s very true in the age of manual claims forms and paper recording in record keeping, however with the use of electronic records in billing there’s often a translation from NDC units to code units which may not be accurately applied. Claims may also require NDC units which can vary based on the code units for the vaccines.
Laura: Sorry, I’m not sure I understand. Isn’t it dose to dose for vaccines?
Chris: You have to take into account multiple considerations based on the NDC that is being billed, such as the dose for a pediatric patient billed differently from an adult dose, so each may crosswalk to a unique code. Also, whether the NDC designates a single dose or a multi-dose vile could affect the unit conversion.
Laura: Okay, I’m starting to understand a little better. Can we go over some examples?
Chris: Sure can. So let’s start with the influenza vaccines. When converting from NDC to Code Units, the conversion can be both Each to Each as in Flumist for which one dose can be given via a nasal route. In this case Each=Each. However, in the next two examples where conversion is from ML to Each, two different ML values, 0.5 and 0.25 convert to 1 Each. For this reason, the crosswalk has to be different for both codes.
Laura: Can we have an understanding of how this could affect the pricing of the vaccine?
Chris: Certainly. So using a product like ReimbursementCodes.com I can use “Global Search” and enter in different pieces of information and come up with the code level price for each of these NDCs as well as the NDC level price as shown here.
Laura: I can see how that can have an effect on reimbursement and there could be either overpayment or underpayment based on the units. If I’m entering a drug dose or NDC units and they get converted to the wrong coding units, the claim can be priced incorrectly.
Laura: What else can cause billing units to be calculated incorrectly?
Chris: Let’s take a look at a different example. Whether the product comes in a single or multi-dose vile can also affect billing units. In this example, there is one billing unit contained in a single-dose vial, and 10 billing-units are contained in a multi-dose vial. In this case, it is helpful that the NDCs cross-walk back to different codes.
Laura: What might occur if these NDCs were billed under the wrong code?
Chris: There could be pricing implications. Let’s go back to reimbursement codes and take a look.
Laura: Chris, I certainly see that this can be a problem. How do I ensure that my correct units will appear on a claim?
Chris: Conversion factors are often incorporated into the claims processing system, so make sure the number of code units entered match the units of measure, and you know which unit type applies to your system and the claim fields you are populating. We also have a unit conversion calculator which can apply a single code unit dose and then apply it to an NDC and convert to those NDC units.
Laura: Chris, are these problems limited to the influenza vaccines or do they extend beyond the flu vaccine?
Chris: Unfortunately they are not limited. There are other examples where dosing NDC and HCPCS code units don’t agree. Pay special attention when billing for a pediatric dose, that the NDC is billed under the pediatric code if one exists.
Laura: I see on the bottom there we’ve got the pediatric code of 90633, and for the adults, they have their code of 90632. I’m starting to understand that each has a different dose, each has a different NDC unit, and that they cross back to the single HCPCS value which makes sense to me, but if you billed it under the wrong code, you might get the wrong reimbursement.
Chris: Exactly, you will be paid under reimbursement or over reimbursement which could open yourself up to audits.
Laura: I have a better understanding of how the incorrect conversion of a unit on a vaccine can affect reimbursement and how billing units can end up being submitted incorrectly. Before you alluded to an incorrect crosswalk to NDC and how that can also cause the same problem like what we just discussed. What else can cause a drug to be incorrectly crosswalked?
Chris: That’s a great question. There are several contributors to crosswalking an NDC to the wrong code. They are not limited to the large number of available codes and NDCs. It could also be due to various interpretations of the description of the codes. The creation date of the new codes can also come into play. There are always new NDCs for influenza in particular generated each year, so use of the proper crosswalk is especially important when the government entities require the submission of the NDC on a claim form.
Laura: How about an example of why an error could occur when selecting a code to fit a particular NDC?
Chris: Sure. A good example is Fluzone Quadrivalent. This year’s NDCs crosswalked to five separate billing codes. When selecting the right code for the vaccine you need to consider a few things; the level of antigen content for the high dose given particularly to patients over 65 years of age, whether a patient is given the pediatric or adult dose or the product was delivered from a prefilled syringe or multi-dose vile.
Laura: Can you show me how this can affect pricing?
Chris: Certainly. So let me do a search for Fluzone Quadrivalent. Here it has multiple different HCPCS codes. Let me select one, and I’ll enter in one billable HCPCS code unit from the calculator. Alright, let’s take note of this price and go back to the search, we’ll do another search for Fluzone Quadrivalent and select a different code, again one billable HCPCS code unit of the NDC and see how they have a different rate here
Laura: Alright. So Chris, what happens if I choose the wrong code and submit it?
Chris: Well, you are not only at risk for improper reimbursement for the drug, but also for claim denial or recovery upon post claim review or audit.
Laura: Alright Chris, we’ve seen how the makeup, form and dose of a vaccine can determine the correct NDC to HCPCS code or CPT crosswalk. What else can factor into the correct code selection?
Chris: Sure. Some payer policies can affect the code to the NDC crosswalk. For example CMS stopped accepting claims billed under the traditional CPT code for Trivalent influenza, and instead required a billing for each brand name vaccine under its own code for Medicare patients. From the example below you would see the CPT code 90658 with a temporary Q code which is very specific to Afluria.
Laura: Okay, great. What would happen if I submitted a Medicare claim under the CPT code instead of the Q code?
Chris: All payment could be denied.
Laura: Okay. So, how do I ensure that I use the correct billing code?
Chris: Well, there are several references to check including payer policies and manuals, the CMS website which includes annual vaccine reimbursement rates. You can also obtain specific billing guidelines from your practice specialty groups such as the ACP-American College of Physicians, AAP-American Academy of Pediatrics, AAFP-The American Academy of Family Physicians and manufactures may also provide guidance on their drugs.
Laura: Okay. Also I’d like to add if you are looking for a central source for this information we at RJ Health provide a comprehensive crosswalk as a software as a service or a SaaS lookup tool. We also provide a file format and as an automated data exception identification via an API. What we’ve been using here today is the SaaS lookup tool. Chris I thank you so much for your time and for shedding some light on some sources of common vaccines coding challenges, and for providing us with some tools to prevent them. Thank you viewer for your time, and please contact us if you have any additional questions or would like to sign up for a free trial of reimbursement codes.
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