ED Coding and Reimbursement Alert

Patient age and means of administration will drive your immunization  code choice.

It is not unusual to provide many flu shots in the ED each flu season, so you’ll want to know about these new codes for 2014.

During the winter months, many EDs see patients without access to primary care who are at risk for developing the flu because of school or housing arrangements that expose them to other who may have influenza. Often these same patients are among the more vulnerable to worse- than-average outcomes from a severe case of the flu, says Betty Ann Price BSN, RN, President and CEO of PRCS, Inc. in Palmetto, FL.

Check Out These Four New Flu Vaccine Codes

• 90685 (Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use) 

• 90686 (Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use)

Two more codes are listed with the lightning bolt symbol “~" indicating they are pending FDA approval:

~• 90687 (Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use)

~• 90688 (Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use)

A new CPT^® code for 2014 describes RIV3:

#• 90673 ( (Influenza virus vaccine, trivalent, derived from recombinant DNA [RIV3], hemagglutinin [HA] protein only, preservative and antibiotic free, for intramuscular use)

Don’t miss: Codes 90672 and 90673 show the hash tag or pond symbol “#” to indicate that they appear out of numerical sequence in the book among the other influenza vaccine codes, says Price.

Make Note of The Other Administration of Flu Vaccine Codes

You’ll want to review the existing influenza vaccine codes as well to be sure you report the one that most accurately describes what is actually given. Say you have a 2 year-old baby brought in because of a persistent cough that lives with siblings often exposed to sick kids from elementary school class. A trivalent, split virus influenza vaccine is given as a precaution. To capture that service report 90655 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use).

Other  possible CPT^® vaccine choices to consider include:

• 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) 
• 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid])
• 90654 (Influenza virus vaccine, split virus, preservative-free, for intradermal use)
• 90655 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use) 
• 90656 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use)
• 90657 (Influenza virus vaccine, trivalent, split virus, when administered to children 6-35 months of age, for intramuscular use) 
• 90658 (Influenza virus vaccine, trivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use) 
• 90660 (Influenza virus vaccine, trivalent, live, for intranasal use)
• 90661 (Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use) 
• 90672 (Influenza virus vaccine, quadrivalent, live, for intranasal use)

Add These HCPCS Codes to Your List As Well

If the chart notes actually name the influenza vaccine by brand name, such as Afluria or Fluzon e HCPCS Q codes are available to identify the vaccine by the brand including:

• Q2034 (Influenza virus vaccine, split virus, for intramuscular use [Agriflu])
• Q2035 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [Afluria])
• Q2036 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [Flulaval])
• Q2037 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [Fluvirin])
• Q2038 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [Fluzone])
• Q2039 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [not otherwise specified])

Don’t forget:  Medicare requires a combination of CPT^® and HCPCS Q codes to identify the manufacturer and dosage mechanism, such as a single dose syringe as opposed to a multi-dose vial.

When the vaccine is furnished in the hospital outpatient department, or FQHC (Federal Qualified Health Center), payment for the vaccine is based on reasonable cost. Medicare will pay for one flu shot per influenza season in the fall or winter, says Price.

Medicare may cover additional seasonal influenza virus vaccinations if medically necessary. 

Administration code G0008 is used with ICD-9 code V04.81, Need for prophylactic vaccination and inoculation against influenza.  The ICD-10-CM code for prophylactic vaccine is Z23.  The service associated with the administration of these vaccine products is separately reported using Immunization Administration for Vaccines/Toxoids codes (90460-90474), Price explains.

For example:  A cancer patient comes in with an exacerbation of acute bronchitis. That episode is stabilized in the ED but is determined that she has not had a flu shot this year. In addition to the ED treatment, also report the influenza vaccine such as 90656 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use) along with G0008 (Administration of influenza virus vaccine) to capture both the vaccine and the administration.