For healthcare providers and medical coders, staying abreast of the latest coding guidelines is crucial, especially when it comes to preventive care. These guidelines ensure accurate billing and compliance, particularly within the context of Designated Health Services (DHS) and exceptions to physician self-referral rules. Understanding the landscape of preventive care coding, initiated with guidelines around 2018, requires a continuous review of updates to CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System) codes. This article will delve into recent updates to these code lists, highlighting key changes and their implications for preventive care services.
2025 Code List: Continued Stability
The most recent update, effective January 1, 2025, reflects a period of stability. Following a public comment period that concluded on December 26, 2024, no comments were received regarding the proposed additions, deletions, or corrections to the code list. This suggests a consensus and smooth transition into the new coding year, maintaining the established framework for preventive care coding.
2024 Code List: Addressing Gaps and Clarifications
The 2024 update, published on November 29, 2023, was more dynamic, demonstrating the responsiveness of coding guidelines to feedback and identified oversights. While most changes proceeded without issue, one significant comment prompted a crucial correction and clarification.
Correction for Hepatitis B and Flu Vaccine Codes
A commenter pointed out an inconsistency concerning Hepatitis B vaccine codes. While most Hepatitis B vaccine codes were correctly identified as qualifying for the exception for preventive screening tests and vaccines under § 411.355(h), CPT code 90739 was missing from this list. This exception is vital as it relates to physician self-referral prohibitions, allowing for certain services under preventive care.
Acknowledging the validity of this comment, the Centers for Medicare & Medicaid Services (CMS) rectified the list to include CPT code 90739 under the preventive screening and vaccines exception. Furthermore, during this review, two additional oversights were identified: CPT codes 90653 and 90658, both related to flu vaccines, were also missing from the exception list. These were subsequently added, ensuring comprehensive coverage for preventive vaccinations.
This update highlights the importance of ongoing scrutiny and feedback in maintaining accurate and effective preventive care coding guidelines. It ensures that patients can access essential preventive services without unnecessary barriers related to coding and billing complexities.
2023 Code List: Smooth Implementation
Similar to 2025, the 2023 annual update, effective January 1, 2023, proceeded smoothly. The public comment period, ending December 30, 2022, yielded no comments concerning additions, deletions, or corrections to the code list. A comment was received regarding service supervision levels, but it was deemed outside the scope of the annual update, indicating a focus on code-specific changes during these updates.
Understanding DHS Categories and Exceptions
The code list is intrinsically linked to Designated Health Services (DHS) categories. These categories, defined by the code list, include:
- Clinical laboratory services
- Physical therapy, occupational therapy, and outpatient speech-language pathology services
- Radiology and certain other imaging services
- Radiation therapy services and supplies
Furthermore, the code list specifies items and services that may qualify for exceptions to physician self-referral prohibitions. Crucially for preventive care, these exceptions include:
- EPO and other dialysis-related drugs (42 CFR § 411.355(g))
- Preventive screening tests and vaccines (42 CFR § 411.355(h))
It’s important to note that some DHS categories are defined separately, without direct reference to the code list, such as durable medical equipment, home health services, and outpatient prescription drugs.
Conclusion: Staying Updated with Preventive Care Coding
Navigating preventive care coding requires continuous attention to updates and clarifications. While the foundational guidelines were established and refined around 2018, annual updates, like those in 2023, 2024, and 2025, ensure the code lists remain accurate, comprehensive, and responsive to the evolving healthcare landscape. The 2024 update, in particular, underscores the importance of vigilance and feedback in maintaining the integrity of these guidelines, directly impacting access to preventive services. For professionals in medical coding and healthcare administration, regularly reviewing these updates is not just a matter of compliance, but a commitment to facilitating effective and accessible preventive patient care.
