Internal Medicine Coding Alert

Internists who provide their patients with pneumococcal and hepatitis B vaccinations need to make sure they are using the correct procedural codes to satisfy the different requirements of Medicare and commercial insurance companies. In addition to covering the administration of the vaccine and the vaccine itself, Medicare will also reimburse for a separate office visit that occurs on the same day as the vaccination.

A large number of Medicare patients will be eligible for a pneumococcal vaccination (PPV), states Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the American Medical Associations (AMA) CPT editorial panel. That would include those persons age 65 and older, as well as those with chronic illnesses such as chronic renal failure, organ transplants, diseases of the immune system and diabetes.

Fewer Medicare patients will be candidates for
hepatitis B, Littenberg believes. The people most likely to be at high risk for hepatitis B are those who could come into contact with contaminated material, blood or needle sticks, he explains. Healthcare workers, disabled patients who become institutionalized and patients who go on dialysis are all likely to be classified as high risk.

CPT and Medicare Use Different Codes

CPT has designated the codes 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid]) and 90472 (each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) for the reporting of the administration of all immunization vaccines. To report the administration of a vaccine/toxoid, the vaccine toxoid codes ... must be used in addition to an immunization administration code(s) 90471, 90472, states CPT 2000. Code 90471 is used to report one immunization, which can be a single or combination vaccine. Code 90472 is used in conjunction with 90471 to report each additional immunization.

However, those CPT codes can only be used to report the administration of a vaccine to a commercial insurance company. Medicare requires the use of the HCPCS codes G0009 for the administration of PPV and G0010 for the administration of the hepatitis B vaccine, according to Littenberg.

Basically Medicare does not cover immunizations and most local payer computer systems are programmed to reject codes 90471 and 90472, he explains. Because PPV and hepatitis B are exceptions to that policy, each vaccine has a separate HCPCS G-code, which is accepted by Medicare.

Medicare does utilize CPT codes, however, for reimbursement of the actual vaccine. Codes covered under Medicares national policy for the vaccines are as follows:

90669 Pneumococcal conjugate vaccine, polyvalent, for intramuscular use

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult dosage, for subcutaneous or intramuscular use

90744 Hepatitis B vaccine, pediatric/adolescent dosage, for intramuscular use

90746 Hepatitis B vaccine, adult dosage, for intramuscular use

90747 Hepatitis B vaccine, dialysis or
immunosuppressed patient dosage, for intramuscular use

Medicares national policy also stipulates that the following ICD-9 diagnosis codes be used in addition to the procedural codes:

V03.82 (vaccination against streptococcus pneumoniae [pneumococcus])

V05.3 (prophylactic vaccination against viral hepatitis)

Separate Office Visit Also Is Covered

Another exception Medicare makes when it comes to PPV and the hepatitis B vaccine is that it will reimburse for an office visit occurring on the same day as the vaccination. The Medicare Carriers Manual states [w]hen an individual or entity administers PPV, influenza virus or hepatitis B vaccines and additional services are provided, the individual or entity may bill for an office visit and Medicare will pay for an office visit if it is reasonable and medically necessary and for other reasonable and other medically necessary services associated with the office visit.

Medicare doesnt reimburse for a separate office visit when an injection is the primary reason for a visit. It also doesnt pay an administration code for an injection when the injection is an add on to an office visit, but these two vaccines are exceptions to the policy, Littenberg notes. These vaccinations can be given as a stand-alone service or can be offered at the same time other services are provided. He suggests that internists attach modifier -25 to the office visit code when reporting the service.

Editors note: Not all state Medicare payers require the use of modifier -25 to report an office visit occurring on the same day as a hepatitis B vaccine or PPV. Internists should check with their local payers to get specific coding instructions.

The office visit must cover more than just the vaccination, however, in order to be eligible for reimbursement. The internist should be seeing the patient for underlying problems, and the subject of vaccination comes up in the course of the discussion, Littenberg explains. If the vaccination is the only purpose for the office visit, no evaluation and management service should be reported.