ED Coding and Reimbursement Alert

Hint: Be aware of imaging, flu vaccine updates.

As emergency departments nationwide prepare to turn their calendars to 2018, it's a good time to brush up on the changes that you'll face when Jan. 1 comes around. From new CPT® codes to the latest flu shot prices, read on to get a handle on how your ED can be ready for the New Year.

1. Pinpoint Flu Shot Codes

Although some may not consider it an "emergency" service, the reality is that many patients receive their flu shots in the emergency department. Not only do physicians encounter patients with compromised immune systems in which a flu shot is recommended, but in other cases, the ED visit may be the patient's sole healthcare encounter the whole year, making it the best time to administer a vaccine.

In the midst of the 2017-2018 influenza season this year, 90682 (Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use) joins 90756 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage,  for intramuscular use) as new additions to CPT^® 2018, "continuing the revisions started last year to focus CPT^® descriptors on dosage while discontinuing age specificity," according Jan Blanchard, CPC, CPMA, a consultant at Vermont-based PCC.

Technically, neither code is new. Code 90682 made its appearance on the AMA web site on July 1, 2016, and became effective January 1, 2017, but 2018 marks the first year it will appear in the CPT^® book. Keep in mind that this code appears out of numerical sequence in the CPT^® book, appearing between codes 90674 and 90673 because of proper placement in the Vaccines and Toxoid section of the code set.

Some payers began accepting 90756 - known by its trade name, Flucelvax - on July 1, 2017. But if your payer is not recognizing the code, you can use 90749 (Unlisted vaccine/toxoid) or HCPCS code Q2039 (Influenza virus vaccine, not otherwise specified) in its place.

You'll also be able to document 90750 (Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection) after the first of the year if your provider administers this vaccination to help prevent an occurrence or reoccurrence of shingles in patients over the age of 60. According to CPT^®, Food andDrug Administration (FDA) approval of this vaccine is pending.

According to CMS data, you'll collect $46.313 from Medicare for 90682 and $22.793 for 90756. To access additional pricing for 2018 vaccines, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html.

2. Take Note of Anthem Policy

If you see patients who are covered by Anthem Blue Cross Blue Shield, it's a good time to brush up on that payer's latest imaging policy, which could negatively impact your pay.

This past summer, Anthem began implementing a new policy that aims to stop paying for MRIs and CT scans performed in hospital-owned outpatient facilities. Instead, Anthem directs these patients to go to independent imaging centers for such scans and tests. The payer expects to have this policy in place across all of its coverage areas by March 2018.

Anthem points to a three-pronged reason for these changes: Improving the patient experience of care, boosting health across populations and cutting the per-capita cost of health care. "Anthem's primary concern is to provide access to quality and safe health care for our members. We are also committed to reducing overall medical cost where possible when the safety of the member is not put at risk," the company said in an FAQ document about the change.

The change is likely to affect hospital or freestanding emergency departments, because they could lose pay for the actual tests performed. The update could also impact availability for advanced imaging in the ED setting, and may cause complaints for emergency physicians after the ED performs testing that prompts high charges which later become the patient's responsibility.

Resource: To read Anthem's announcement about the changes, visit https://www11.anthem.com/provider/in/f4/s0/t0/pw_g303738.pdf.

3. Be Ready for ICD-10 Changes

Although ICD-10 changes actually went into effect on Oct. 1, they are still crucially important as you venture into 2018. You should ensure that your superbills are completely updated and that your charge systems have been overhauled to remove any deleted codes and add any new ones. In addition, make sure your descriptors are revised when applicable.

For instance, Section I50- "Heart failure" added a new category (I50.8-,  Other heart failure) for 2018. The ICD-10 manual offers new codes to specify when patients have conditions that fall under this category such as right ventricular failure or biventricular heart failure. These additions include the following:

• I50.81- (Right heart failure)

            o I50.810 (Right heart failure, unspecified)
            o I50.811 (Acute right heart failure)
            o I50.812 (Chronic right heart failure)
            o I508.13 (Acute on chronic right heart failure)
            o I508.14 (Right heart failure due to left heart failure)

• I50.82 (Biventricular heart failure)
• I50.83 (High output heart failure)
• I50.84 (End stage heart failure)
• I50.89 (Other heart failure).

ICD-10 2018 also brings you new codes for pulmonary hypertension, which affects the arteries in the lungs and the heart. Your new code choices are as follows:

• I27.20 (Pulmonary hypertension, unspecified)
• I27.21 (Secondary pulmonary arterial hypertension)
• I27.22 (Pulmonary hypertension due to left heart disease)
• I27.23 (Pulmonary hypertension due to lung diseases and hypoxia)
• I27.24 (Chronic thromboembolic pulmonary hypertension)
• I27.29 (Other secondary pulmonary hypertension).

In general, adding the new codes for cardiology is a movement in the right direction for more specificity as to the cause of the disease state, according to Mary I. Falbo, MBA, CPC,  CEO of Millennium Healthcare Consulting Inc.

"The new codes allow for more specific reporting, which will help the physician code to the level of specificity so he can ensure that the ordering of tests, visits, etc., meets medical necessity guidelines in terms of frequency of visits and the need for diagnostic testing," Falbo adds.

4. Prep for New CPT^® Codes

Although it may seem like there's plenty of time to prepare for the 2018 CPT^® codes, the reality is that you should have them ready to implement well before Jan. 1. After that date, your payers will immediately deny any claims that include deleted CPT^® codes, which could cause a flood of denials.

Remember, for instance, that you now have four chest x-ray codes (71045-71048) and that the existing codes from this category (71010-71035) will be deleted effective Jan. 1. In addition, remember that the observation codes (99217-99220) now have the words "outpatient hospital" inserted before the term "observation status." Therefore, it appears that CPT^® will only allow the observation service codes in the outpatient hospital setting, rather than observation being a "status" like in the past.