Influenza Vaccine: CMS Holding Claims for CPT Code 90658
From CMS:
CMS is aware of an issue affecting payment for CPT code 90658:
- Long descriptor: Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
- Short descriptor: IIV3 VACCINE SPLT 0.5 ML IM
We’re holding claims for CPT code 90658 for dates of service on or after August 1, 2024, until October 7, 2024.
Your Medicare Administrative Contractor will reprocess any denied claims by November 1, 2024. You don’t need to take any action.
Billing Errors on 2024/2025 Influenza Season Claims
From National Government Services:
The influenza season runs from August 1st of each year until July 31st the following year. Every influenza vaccine is assigned a new NDC each season. This season, some codes no longer have a published fee from CMS. When this occurs, National Government Services will manually price the claims until a fee is established.
We are receiving large volumes of claims with the incorrect NDC or the wrong code based on the NDC for the influenza vaccine for the 2024-2025 flu season. If you receive a billing error denial for the last or the current flu season, please verify the correct NDC and/or CPT is being used. Failure to use the correct CPT/NDC combination and/or using the incorrect flu season NDC will result in a billing error denial. If you find an error, please correct and resubmit the claim.
2024/2025 codes without a fee schedule from CMS are: 90672, 90674, 90682, 90686, 90687, 90688, 90694 and 90756. Visit CMS’ Vaccine Pricing web page for listed fees.
As a reminder, be sure you are using the correct administration code of G0008 for the influenza vaccine. G0008 must be used as it is not subject to the deductible and coinsurance. Do not use 90471/90472 for the administration of the influenza vaccine.
Updated COVID-19 Vaccines for 2024-2025 Season
From CMS:
The FDA approved updated COVID-19 vaccines for the 2024–2025 season:
- mRNA vaccines made by Pfizer-BioNTech and Moderna on August 22, 2024
- Novavax COVID-19 Vaccine, Adjuvanted on August 30, 2024
These vaccines target currently circulating variants and provide better protection against serious consequences of COVID-19, including hospitalization and death:
- Pfizer-BioNTech and Moderna COVID-19 vaccines include a monovalent (single) component that corresponds to the Omicron variant KP.2 strain of SARS-CoV-2
- Novavax COVID-19 Vaccine, Adjuvanted includes a monovalent (single) component that corresponds to the Omicron variant JN.1 strain of SARS-CoV-2
CMS updated COVID-19 vaccine pricing for the 2024–2025 season:
- CPT codes 91318–91322 effective August 22, 2024 (Note: no change to payment allowances from last season for 91318–91319)
- CPT code 91304 effective August 30, 2024
Use CPT code 90480 to bill for the administration of the vaccine.
Visit the COVID-19 Vaccine Provider Toolkit for more information.
Reminder from Excellus BlueCross BlueShield- Annual Well-Woman Exam Billing Requirement
From Excellus:
Annual well-women exams should be billed using CPT codes 99381-99397 to distinguish between the annual physical exam and annual gynecological exam. Using these codes helps avoid receiving a claim denial due to benefit exhaustion.
OB/GYNs serve as primary care providers for many women and the annual women visit can provide an opportunity to counsel patients about achieving a healthy lifestyle. Primary care and gynecological care providers can bill for both these services in the same year. The Health Plan requires a gynecological exam diagnosis code to be billed in the first listed position for the claim to adjudicate properly.
Bill an annual GYN visit using CPT codes 99385-99387 and 99395-99397 with the primary dx code Z01.411 or Z01.419 as defined below:
Z01.411 — Encounter for gynecological examination (general) (routine) with abnormal findings
Z01.419 — Encounter for gynecological examination (general) (routine) without abnormal findings
These codes can be used as the ICD-10-CM diagnosis code for the annual exam performed by an OB/GYN.
If a pelvic exam is also performed, CPT code 99459 can be billed for the technical portion of the pelvic exam. It should be billed with the annual exam codes 99385-99387 or 99395-99397.
New Medicare Advantage PPO Plans in Maryland Effective 1/1/2025
CDPHP Issuing Official Explanation of Payments
ICD-10 Code Set Update Effective October 1, 2024
The update to the ICD-10 Code Set includes 252 new codes, 36 code deletions, and 13 code revisions. Here is a brief breakdown of the updates:
Chapter 2- there are several new codes and some have been expanded to include 5th character “A” to indicate cancer in remission.
Chapter 4- new codes added under E10 (Type 1 Diabetes), E16 (hypoglycemia levels), E34.00-E34.09 (carcinoid syndrome), E66.811-E66.813 (obesity class), E74.82 (disorders of citrate metabolism) and E88.82 (Obesity due to disruption of MC4R pathway).
Chapter 5- several new codes under F50 (eating disorders) to include F50-.010-F50.019, F50.020-F50.029, F50.20-F50.25 and F50.810-F50.819.
Chapter 6- changes under G40 (Epilepsy and recurrent seizures) including new codes G40.84, G40.841-G40.844, G90.81, G90.889 and G93.45.
Chapter 9- new codes I26.03-I26.04, I26.95-I26.96 expand the Pulmonary Embolism subcategory.
Chapter 10- Under J21 (Acute Bronchiolitis) there are new codes for nasal valve collapse.
Chapter 11- new 5th and 6th character codes added under K60.3, K60.4, and K60.5 (Anal fistula, Rectal fistula, and Anorectal fistula).
Chapter 12- Under L29 (Pruritis) there are new codes L29.81 (cholestatic pruritis) and L29.89 (other pruritis).
Chapter 13- New codes for diseases of the musculoskeletal system and connective tissue. Under subcategory M65 (Synovitis and tenosynovitis) there are several 5th and 6th digit character codes to specify location.
Chapter 17- 3 new codes for congenital malformations of aortic and mitral valves (Q23.81-Q23.82, Q23.88) and one new code for Kleefstra syndrome (Q87.86).
Chapter 18- 1 new code for Anosognosia R41.85.
Chapter 19- under subcategory T45 (Poisoning…) there is a new code T45.A along with several new 5th and 6th character codes that specify the circumstances of the poisoning, adverse effect, or underdosing. Under T81.32 (Disruption of internal operation wound) there are new 6th character codes T81.320-T81.329 to specify wound location.
Chapter 21- new codes Z15.1 and Z15.2.
For a complete review of the changes, click here.