May 17, 2018
Like diagnosis codes, procedure codes can be age-banded, so be sure to choose accurate age-banded procedure codes to avoid claims denial and extra work to resubmit the claim. You’ll find age range guidelines in both the CPT and HCPCS code sets/codebooks.
To help you identify possible opportunities for changes to reduce your claim denials, here are the two key areas where most of the edit denials occur:
Preventive Medicine Examination codes (CPT codes 99381-99397)
These codes are broken out between new and established patients and by the patient’s age. The patient’s age at the time of the visit determines which code to select, not the patient’s age when the bill was generated. Some examples of preventive medicine codes and their age bands include:
- 99381 – Initial comprehensive preventive medicine E&M (evaluation and management) of an individual, including an age and general appropriate history, exam, counseling/guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures; new patient; infant (age younger than 1 year)
- 99384 – new patient, adolescent (age 12 through 17 years)
- 99386 – new patient, adult 40-64+ years
- 99393 – established patient; late childhood (age 5 through 11 years)
- 99395 – established patient, adult 18-39 years
- 99397 – established patient, adult 65 years and older
A common mistake is that providers submit an adult preventive medical exam code for a teenaged patient.
Vaccine administration codes (CPT codes 90460-90474)
The vaccine administration codes are differentiated in the CPT Codebook based on the age of the patient at the time of exam, codes for patients through age 18 years, and a different set of administration codes for patients over 18 years of age. To avoid a denial and potential resubmission of the claim, choose the correct vaccine administration code to match your patient’s age:
- Administration codes for patients through age 18 years:
- 90460 – Immunization administration through 18 years of age
- +90461 – each additional vaccine or toxoid component
- Administration codes for patients over 18 years of age:
- 90471 – Immunization administration, percutaneous, intradermal, subcutaneous or intramuscular; one vaccine
- +90471 – each additional vaccine
- 90473 – Immunization administration by intranasal or oral route; one vaccine
- +90474 – each additional vaccine
We’ll continue to edit for these age-to procedure conflicts. To avoid future line or claim denials, review the coding guidelines and information in your coding applications or the 2018 CPT Professional Codebook.