Search This Blog

CMS Will Pay for COVID-19 Booster Shots

Coverage without cost-sharing available for eligible people with Medicare, Medicaid, CHIP, and Most Commercial Health Insurance Coverage

Following the FDA recent action that authorized a booster dose of the Pfizer COVID-19 vaccine for certain high-risk populations and a recommendation from the CDC, CMS will continue to provide coverage for this critical protection from the virus, including booster doses, without cost sharing.

Beneficiaries with Medicare pay nothing for COVID-19 vaccines or their administration, and there is no applicable co-payment, coinsurance, or deductible. 

In addition, thanks to the American Rescue Plan Act of 2021, nearly all Medicaid and CHIP beneficiaries must receive coverage of COVID-19 vaccines and their administration, without cost-sharing. COVID-19 vaccines and their administration, including boosters, will also be covered without cost-sharing for eligible consumers of most issuers of health insurance in the commercial market. 

CMS continues to explore ways to ensure maximum access to COVID-19 vaccinations

New COVID-19 Vaccine Codes - September'2021

Immunization Administration 

0001A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; first dose.

0002A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; second dose.

0003A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose.

0004A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; booster dose.

  • Report 0001A, 0002A, 0003A, 0004A for the administration of vaccine 91300


0051A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; first dose.

0052A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; second dose.

0053A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; third dose.

0054A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; booster dose.

  • Report 0051A, 0052A, 0053A, 0054A for the administration of vaccine 91305


0011A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; first dose.

0012A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; second dose.

0013A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose.

  • Report 0011A, 0012A, 0013A, for the administration of vaccine 91301


0064A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, booster dose.

  • Report 0064A for the administration of vaccine 91306


Expand Vaccination Requirements

The overall will protect patients of the 50,000 providers and over 17 million health care workers in Medicare and Medicaid certified facilities for COVID-19 Vaccines.

The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), announced that emergency regulations requiring vaccinations for nursing home workers will be expanded to include,

  • Hospitals, 
  • Dialysis facilities, 
  • Ambulatory surgical settings, 
  • Home health agencies.

Nursing homes with an overall staff vaccination rate of 75% or lower experience higher rates of preventable COVID infection. 

In CMS review of available data, the agency is seeing lower staff vaccination rates among hospital and End Stage Renal Disease (ESRD) facilities. 

To combat this issue, CMS is using its authority to establish vaccine requirements for all providers and suppliers that participate in the Medicare and Medicaid programs. 

Vaccinations have proven to reduce the risk of severe illness and death from COVID-19 and are effective against the Delta variant.

CMS is developing an Interim Final Rule with Comment Period that will be issued in October.  

CMS expects certified Medicare and Medicaid facilities to act in the best interest of patients and staff by complying with new COVID-19 vaccination requirements.  

Health care workers employed in these facilities who are not currently vaccinated are urged to begin the process immediately. 

Facilities are urged to use all available resources to support employee vaccinations, including employee education and clinics, as they work to meet new federal requirements.

Conventions and General Coding Guidelines - PART 3

Continuation of PART 2

Etiology/Manifestation Convention

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the  ICD-10-CM  has a  coding convention that requires the underlying condition to be sequenced first, if applicable, followed by the manifestation. 

Wherever such a  combination exists,  there is a “use additional code” note at the etiology code,  and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes,  etiology followed by manifestation. 

In  most cases, the manifestation codes will have in  the code  title,  “in  diseases classified elsewhere.”  Codes with this title are components of the etiology/ manifestation convention. 

There are manifestation codes that do not have  “in diseases classified elsewhere” in the title. For such codes,  there is a  “use additional code” note at the etiology code and a “code first” note at the manifestation code,  and the rules for sequencing apply.

“Code first”  and  “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/ manifestation combination. 

And

The word “and” should be interpreted to mean either “and” or “or” when it appears in a title. For example, cases of  “tuberculosis of bones”, “tuberculosis of joints”  and “tuberculosis of bones and joints” are classified to subcategory  A18.0, Tuberculosis of bones and joints.

With 

The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title,  the Alphabetic Index  (either under the main term or subterm),  or an instructional note in the Tabular  List.  

The classification presumes a causal relationship between the two conditions linked by these terms in the  Alphabetic Index or  Tabular  List.  

These conditions should be coded as related even in the absence of provider documentation explicitly linking them unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a  documented linkage between two conditions  

(e.g.,  sepsis guideline for  “acute organ dysfunction that is not clearly associated with the sepsis”). 

Code Also Note

A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.  The sequencing depends on the circumstances of the encounter.

Default Codes 

A code listed next to a main term in the ICD-10-CM Alphabetic  Index is referred to as a default code The default code represents that condition that is most commonly associated with the main term or is the unspecified code for the condition. If a condition is documented in a  medical record  (for example, appendicitis) without any additional information,  such as acute or chronic, the default code should be assigned. 

Conventions and General Coding Guidelines - PART 2

Continuation of PART 1 

Includes Notes 

This note appears immediately under a three-character code title to further define, or give examples of,  the content of the category. 

Inclusion Terms

A list of terms is included under some codes. These terms are the conditions for which that code is to be used.  The terms may be synonyms of the code title, or, in the case of “other specified” codes,  the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the  Alphabetic Index may also be assigned to a code. 

Excludes Notes 

The  ICD-10-CM  has two types of excludes notes. Each type of note has a  different definition for use,  but they are all similar in that they indicate that codes excluded from each other are independent of each other. 

Excludes1 

A type1 Excludes note is pure excludes note. It means “NOT  CODED HERE!”  An  Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1  note.

Excludes2 

A type 2 Excludes note represents “Not  included here.” An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.

Code Assignment and Clinical  Criteria

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a  particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. 

ICD-10 CM Conventions and General Coding Guidelines - PART 1

Format and Structure

The Tabular List contains are Categories Subcategories codes.  

All categories are 3 characters. A three-character category that has no further subdivision. The Subcategories are either 4 or 5 characters. The Codes maybe 3,  4, 5,  6, or  7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a  code. 

Placeholder Character

The ICD-10-CM utilizes a placeholder character  “X”.  The “X” is used as a placeholder at certain codes to allow for future expansion. 

An example of this is at the poisoning, adverse effect, and underdosing codes, categories  T36-T50.  Where a placeholder exists, the X  must be used in order for the code to be considered a valid code

NEC - Not  Elsewhere Classifiable

NEC - This  abbreviation  in the  Alphabetic  Index & Tabular List represents “other  specified.” When a  specific code is not available for a  condition,  the  Alphabetic Index directs the coder to the “other specified”  code in the  Tabular  List. 

NOS - Not Otherwise Specified 

NOS - This abbreviation is the equivalent of unspecified. 

Punctuation

[ ] Brackets are used in the  Tabular  List to enclose synonyms, alternative wording, or explanatory phrases. Brackets are used in the  Alphabetic  Index to identify manifestation codes. 

( ) Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. 

: Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

Other Specified Codes

“Other” codes Codes titled  “other”  or  “other specified”  are for use when the information in the medical record provides detail for which a specific code does not exist in the alphabetic index or Tabular list

Unspecified Codes

 “Unspecified” codes Codes  titled  “unspecified”  are for use when the information in the medical record is insufficient to assign a more specific code.

Usage of ICD 10 CM - Drive the Codes

Alphabetic Index and Tabular List

The ICD-10-CM is divided into two main part,

  • Alphabetic Index 
  • Tabular List

Alphabetic Index

An alphabetical list of terms and their corresponding code and contains the following parts.

  • Diseases
  • Injury
  • External Causes of Injury
  • Neoplasms Table
  • Drugs and Chemicals Tables

Tabular List 

A structured list of codes divided into chapters based on body system or condition.

Drive the Codes

To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record.

First, locate the term in the Alphabetic Index, and then verify the code in the Tabular List.

Read thoroughly and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.

It is essential to use both the Alphabetic Index and Tabular List when driving and assigning a code. The Alphabetic Index does not always provide the full code.

Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List.

A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.


Stay connected continuation of the ICD 10 CM guidelines -PART 1

Update to Medicare Deductible, Coinsurance & Premium Rates - 2021

Medicare Deductible, Coinsurance  Rates'2021

The Centers for Medicare & Medicaid Services (CMS) issued for the 2021 deductibles, coinsurance, and premium rates for beneficiaries covered through the Medicare fee for service program. 

The 2021 deductible, coinsurance, and base premium rates are below and effective from 01/01/2021

2021 Part B - Supplementary Medical Insurance (SMI)

Based on Part B, the Medicare Supplementary Medical Insurance (SMI) program, enrolls are subject to a monthly premium. 

Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrolled must pay), which are set by statute.

  • Standard premium: $148.50 a month
  • Deductible: $203.00 a year
  • Pro-Rata  Data  Amount 
  • $145.31  for  the  1st  month 
  • $57.69  for  the  2nd  month
  • Coinsurance: 20%

2021 Part A - Hospital insurance

  • Deductible: $1,484.00
  • Coinsurance
  • $371.00 a day for days 61 through 90
  • $742.00 a day for days 91 through150 (lifetime reserve days)
  • $185.50 a day for days 21 through 100 (Skilled nursing facility coinsurance)

Usage of CPT Index - Instructions

The alphabetic index is not a substitute for the main text of the CPT codebook.

Even if only one code is present, the coder must refer to the main term to ensure that the code is selected accurately and correctly to identify the services rendered.

Main Terms

The index is organized by main terms. Each main term can stand alone or can be followed by up to three modifying terms.

There are four primary classes of main entries,
  • Procedures or Services - E.g, Scopic, Anastomosis, Splint, Opening
  • Organ or Other Anatomical Site - E.g, Knee, Arm, Ear, Tibia, Colon
  • Conditions - E.g, Abscess, Entropion, Tetralogy of Fallot.
  • Synonyms, Eponyms, and Abbreviations. - ECG, EEG, PET, Brock Operations, Clagett Procedures

Modifying Terms

The main term may be followed by up to three indented terms that modify the terms they follow.
EG. The main term "Endoscopy" is subdivided by the anatomical sites in which the procedure is used. And within these anatomical sites, the specific purpose of the procedures is identified.

In the following example, The code for endoscopic removal of a foreign body from the bile duct could be located.
  • Bile Duct
    • Removal
      • Foreign Body........ 43275

Code Ranges

Whenever more than one code applies to a given index entry, a code range is listed. If several inconsequential codes apply, they will be separated by a comma. In the following example, three inconsequential codes apply,
  • Esophagus
    • Reconstruction ......... 43300, 43310, 43313
If three or more sequential codes apply, they will be separated by a hyphen. If more than one code range applies the code ranges will be separated by a comma as in the following example,
  • Anesthesia
    • Forearm...............01810-01820, 01830-01860

Conventions

As a space-saving convention, certain terms carry meaning inferred from the context. This convention is primarily used when a procedure or service is listed as a sub-term.

Example,
  • Knee
    • Exploration .............. 27310,27331

Pathology & Laboratory Codes

The pathology and Laboratory listing in the index presents the headings, subheadings, procedures, and analyzes in the Pathology and Laboratory action of the CPT codebook.

Analytes are either listed alphabetically or cross-referenced to the index main heads where they are alphabetically listed.

ICD 10 CM Updates

Guidelines for billing CPT G2211

About CPT G2211 & Objectives Effective from January 1, 2024, the Centers for Medicare and Medicaid Services (CMS) began reimbursing for ...