Measles Outbreak: Infectious Diseases Billing And Coding Mastery For Clean Claim Submission

Recently, a measles outbreak has been reported in Pennsylvania, putting clinics and hospitals on high alert, and creating an operational strain on healthcare providers and practices. In this article, we will guide you to apply exact measles billing and coding rules, making your rendered health services fully compliant to regulations yet ensuring full reimbursement throughout the RCM process. When primary care providers confront such surges during epidemics, administrative sides have to loosen on fulfilment of duties to cover more important aspects like emergency vaccinations and PCR swabs for diagnosis of suspected exposures. This results in losing the revenue to denials eventually because focusing on services rendered distract the attention required to perform billing and coding for infectious diseases.

Specificity Rules For Infectious Diseases Billing and Coding (Diagnosis Codes)

A DX code that doesn’t specify the diagnosis completely, will be treated as truncated code.  A truncated code is a code that is submitted for payment incompletely and with fewer specifications (less than specific number of characters required). A diagnosis code for Measles with complications, B05.8, is not payable if submitted as a header code i.e. B05. This is a common mistakes in billing and coding for infectious diseases, and will immediately trigger clearinghouse rejections or denials. A set of non truncated fully billable measles codes from ICD 10 CM are:

• B05.9 – Measles without complications (uncomplicated confirmed cases)
• B05.0 – Measles complicated by encephalitis
• B05.1 – Measles complicated by meningitis
• B05.2 – Measles complicated by pneumonia
• B05.3 – Measles complicated by otitis media
• B05.81 – Measles keratitis and keratoconjunctivitis
• Z20.828 – Contact with and (suspected) exposure to other viral communicable diseases (use for asymptomatic patients presenting after outbreak exposure)
• Z23 – Encounter for immunization (primary diagnosis for routine or catch-up MMR vaccination)

Important: Care Medicus experts advise to never report B05.xx in a single claim as A81.1 following the ICD 10 “Excludes1” edits.

Infectious Diseases Billing and Coding Rules For Commercial Payers

During epidemics, while submitting rendered services to commercial payers for reimbursement, bill only for treatment codes and administration codes. Commercial payers and state vaccines programs for children (VFC) strictly separate lab testing, vaccination costs, and counseling-based administration fees. Below, a list of clean claim execution rule against each service type and their CPT codes is given for a general understanding of infectious diseases billing and coding (measles specific).

Read More >> Struggling With Prostheses Billing Services? Here is How to Fix Them Quickly

3 Critical Checks To Ensure Clean Claim Submission

• Do not assign B05.9 to a patient seeking evaluation (post exposure). Till symptoms of measles are confirmed by laboratory reports, use Z20.828.
• Modifier 25 should be strictly appended to the E/M code during distinct problem oriented evaluation with the administration of MMR vaccine. 99213 will always be recorded with modifier 25, while 90707 or 90460 should never be reported with modifier 25.
• Mandatory public health reporting should be documented. Pennsylvania’s 24 hour reporting rule obligate the provider to inform health authorities for suspected cases through immediate notification (28 Pa. Code §27.21a). To justify higher billing rates to the payers and public health officials during audits, complex visits like 99214 or 99215 often require documented proofs of steps taken to evaluate the patient.

Read More About Guidelines of Measles Billing and Coding