Pediatric Coding Alert

Vaccine administration payment, telehealth, under Medicare’s microscope.

Given the current state of the pandemic, it’s not surprising that the two most significant issues for pediatric practices addressed in the Medicare Program; CY 2022 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies Proposed Rule are related to the COVID-19 public health emergency (PHE).

Not only has Medicare waived many policies affecting telehealth because of the PHE, but payment for the COVID-19 vaccines introduced late last year has brought renewed scrutiny to vaccine administration pricing as a whole.

So, it’s no wonder that you have plenty of questions about how Medicare’s proposals will affect your coding and billing in CY 2022. Here they are, along with our expert answers.

What’s Going to Happen to Immunization Administration Payments?

“The main thing that really stands out for pediatrics in the proposed rule is the continued deliberation about immunization administration payments that we’ve watched play out over the last several years,” notes Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC.

The COVID-19 pandemic has renewed that debate between Medicare and stakeholders on two fronts. First, Medicare has based payments for preventive vaccines, most notably for the influenza, pneumococcal, and hepatitis B virus (HBV) vaccines, “on 95 percent of the Average Wholesale Price (AWP) for a particular vaccine product” (p. 298).

Additionally, Medicare reduced the payment for 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular), 90460/+90461 (Immunization administration through 18 years of age … with counseling by physician or other qualified health care professional; first or only component of each vaccine …); 90471/+90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine…); and 90473/+90474 (Immunization administration by intranasal or oral route; 1 vaccine…) as the following table shows:

In the meantime, on March 15, 2021, Medicare increased payments for COVID-19 vaccines from $16.94 to $40.00 for the first doses of the Pfizer and Moderna vaccines (billed with 0001A and 0011A, respectively), from $28.39 to $40.00 for the second doses of the Pfizer and Moderna vaccines (billed with 0002A and 0012A, respectively), and from $28.39 to $40.00 for the single-dose Jannssen/Johnson & Johnson vaccine (billed with 0031A).

Because of this, Medicare is “requesting feedback from stakeholders that would support the development of an accurate and stable payment rate for administration of … preventive vaccines [and] establishing payment rates for these services that could be appropriate for use on a long-term basis” (p. 303).

As these codes are so important in pediatrics, “I recommend that readers weigh in on this important topic by submitting their feedback,” says Blanchard.

Will Temporary Telehealth Services Become Permanent?

As expected, the proposed rule provided a glimpse into the status of telehealth once the PHE ends, including proposals on which Category 3 services (services temporarily added to the Medicare telehealth services list for the COVID-19 PHE) will become permanent and how long the others will continue.

As a reminder, Medicare added a total of 135 services to the Medicare telehealth services list on a Category 3 basis in 2020, with several more added this year.

Medicare’s proposal for the Category 3 codes is “to retain all services added to the Medicare telehealth services list on a Category 3 basis until the end of CY 2023. This will allow us time to collect more information regarding utilization of these services during the pandemic, and provide stakeholders the opportunity to continue to develop support for the permanent addition of appropriate services to the telehealth list through our regular consideration process” (p. 92).

Medicare also added a number of other services to the telehealth list during the PHE that were not on the Category 3 list and that will disappear from the list when the government formally ends the PHE — unless Medicare is persuaded by public comment to place them on the Category 3 list.

This proposal affects a number of codes that can be used in a pediatric setting, including various tympanometry and audiology tests; numerous behavioral health services, including developmental testing and screening codes; observation care services; pediatric critical care services; and virtual check-in codes 99441-99443 (Telephone evaluation and management service by a physician or other qualified health care professional …).

Will We Wave Goodbye to the Telehealth Waivers?

The proposed rule firmly says that “at the conclusion of the PHE for COVID-19, associated waivers and interim policies will expire.” This will mean a return to rural/site limitations, to HIPAA-compliant software, and to payments adjusted back to the facility rate for any telehealth services you bill to Medicare once the PHE has ended (p. 91) if the proposal is finalized.

(To view the full proposed rule, go to >public-inspection.federalregister.gov/2021-14973.pdf?utm_medium=email&utm_campaign=pi+subscription+mailing+list&utm_source=federalregister.gov. CMS will accept comments on the proposed rule electronically, via regular mail, and by express or overnight mail, until 5 p.m. on September 13, 2021. See page 2 of the proposed rule for further information).