As the country is responding to the latest Public Health Emergency (PHE) of the ongoing spread of the monkeypox virus, the Biden-Harris Administration has increased response efforts to ensure that communities across the country have access to the prevention and treatments needed. Is your organization up to date on the American Medical Association (AMA) and Center for Medicare and Medicaid Services (CMS) coding/billing guidelines for these new tests and immunizations?
While additional guidance will be forthcoming as the U.S. Department of Health & Humans Services (HHS) and the Center for Disease Control and Prevention (CDC) continue to address the spread of the virus, healthcare leaders do already have direction and guidance on how CMS expects us to bill for these services.
AMA Bulletin
In July, the AMA issued a special edition bulletin outlining the CPT/HCPCS codes that are approved for testing for the virus, vaccine codes, as well as the CPT codes for the administration of the vaccine. Later, on July 26th, CPT 87593 was put into effect for labs around the country to test for monkeypox virus (Infectious agent detection by nucleic acid (DNA or RNA); orthopoxvirus (eg, monkeypox virus, cowpox virus, vaccinia virus), amplified probe technique, each).
Currently, there are two different codes for the available vaccines/toxoids. The first 90611 (JYNNEOS) is a combo vaccine for smallpox and monkeypox, which is a 0.5 mL, dosage suspension for subcutaneous injection for patient aged 18 and older which will require two doses 28 days apart. The second code 90622 (ACAM2000) is a single 0.3mL dose (smallpox) vaccine for patients ages 12 months and older. The FDA has approved the use of this vaccine to protect against monkeypox.
Vaccine Codes
Like the COVID-19 vaccine, currently the federal government is providing vaccines to healthcare organizations and counties which means that the vaccine itself is not reimbursable. However, when billing for the administration of a vaccine, the medication code must be present on the claim form with a fee of either $0 or $0.01 depending on your organization’s billing standard. CMS will accept either. Claims must also have standard administration codes outlined by the vaccine code that matches the age and corresponding administration provided during the patient encounter.
The approved standard vaccine administration codes are:
- 90460 IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX
- 90461 IM ADM THRU 18YR ANY RTE ADDL VAC/TOX COMPT
- 90471 IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE
- 90472 IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE
Implement New Processes
As you implement billing processes around these new tests and vaccines, I recommend the following:
- Work closely with your Provider Relations team to align with Medicaid and Commercial payors to ensure they are adhering to the AMA and CMS coding/billing guidelines
- Develop a tracking document that tracks communication with and guidance from each payor
- Partner with your Revenue Cycle Claims IT, Analyst, to set up your claims and claim edit to each unique requirement
- Check with your clearinghouse to ensure they have configured their system to match both CMS and commercial payor requirements so your claims can go out the door clean the first time
- Start with a small test batch of claims to each payor to confirm the claims were received and monitor them through claims processing
- Once test claims have been paid, confirm claims were paid as expected prior to releasing all claims for that payor
If you have more questions about chargemaster configuration, claims configuration, denials prevention, or implementing a structure to improve your revenue cycle goals more broadly, we’re here to help! Contact us at The Wilshire Group.
Sited:
https://www.ama-assn.org/system/files/cpt-assistant-guide-monkeypox-july-2022.pdf
