Internal Medicine Coding Alert

Hint: Don’t forget to report administration with separate codes.

As your code choices for influenza vaccines increase every flu season, you might be finding coding for flu vaccinations daunting – look at route of administration, strains of influenza the vaccine is effective against, age of the patient and presence of preservatives to help drive your vaccine code choice.

Tip 1: Capture Vaccine Strains to Initiate Code Choice

The first thing that you will need to look at when trying to discern what codes you will report for the vaccine is to look at the number of strains of influenza virus that the vaccine will protect the patient from. Although most of the vaccines that were available till now protected the patient from two strains of Influenza A (H1N1 and H3N2) and one strain of Influenza B (trivalent), you now have newer vaccines that will protect the patient from four strains of influenza, namely two strains of influenza A and two strains of influenza B (quadrivalent).

So, when looking at the product label, you will have to look at terms like “trivalent” and “quadrivalent” that will help you in narrowing down your code choice and assist you to choose the appropriate code.

Reminder: Many of the available influenza vaccines such as Fluzone and Flulaval, which were only available as “trivalent” vaccines earlier, are now available in the quadrivalent series also. So, it is best to check the product label or check with your internist to see which form of the vaccine he used to avoid making costly mistakes in coding and losing out on reimbursement.

Tip 2: Look at Route of Vaccine Administration

While most of the code choices that you have for flu vaccine coding is for intramuscular or other injected forms of the vaccine, new vaccines that can be used as a spray have brought in a few more choices. So, if your internal medicine physician is using an influenza vaccine such as FluMist in the form of a spray, you’ll have to select from either 90660 (Influenza virus vaccine, trivalent, live, for intranasal use) or 90672 (Influenza virus vaccine, quadrivalent, live, for intranasal use) depending on the number of strains that the vaccine will protect the patient from.

Note: Even the administration code will vary by route of the administration. For example, if the vaccine is provided by the intranasal route without counseling, you will report 90473, Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid] and +90474 for each additional vaccine that is provided by the intranasal or oral route in the same session). “By comparison, if the administration without counseling is percutaneous, intradermal, subcutaneous, or intramuscular, then you will report 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 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)),” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. However, the administration code will remain the same irrespective of the route when vaccination along with counseling about the vaccine is provided to a patient 18 years of age or younger (90460, Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered and +90461 for each additional vaccine or toxoid component when more than one is provided with counseling).

Tip 3: Check Age of the Patient For Injected Vaccines

You do not have different code choices depending on the age of the patient for intranasal vaccines, but you have to look for age of the patient to whom the vaccine is provided for injected forms.

For each type of influenza vaccine, you have two code choices depending on the age of the patient, one for ages between six months and 35 months and another for ages three years and above.“For instance, code 90657 is for ‘Influenza virus vaccine, trivalent, split virus, when administered to children 6-35 months of age, for intramuscular use,’” points out Moore. “The corresponding code for individuals three years of age and older is 90658.”

Tip 4: Determine If the Vaccine Was Preservative-Free or Not

Next, you look at whether or not the vaccine contains any preservatives. Some of the clues that you can look at in the product label is to look for constituents such as “thimerosol.” If this is present in the product, then the product contains a preservative. Products without a preservative are considered “preservative-free.” “The trivalent, split virus influenza virus vaccines described by 90657 and 90658 above are considered to include preservative, since the phrase “preservative-free” is not included in the descriptors,” observes Moore. The corresponding codes for preservative-free, trivalent, split virus influenza vaccine are 90655 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use) and 90656 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use).

Caveat: Most of the commercially available flu vaccines come in “single-use” doses and “multi-dose” packs. Some of the vaccines that you would be using might be preservative free when your physician is using a single-dose pack while the multi-dose pack with the same brand name might contain preservatives. So, look at the product label prior for preservatives, or else you might end up reporting wrong.

Example: Your physician provides a dose of Fluzone intramuscularly to a child aged two and half years. The product label shows that a 0.25mL single dose pack was used. The product label also shows that the product used is a trivalent, split virus inactivated influenza virus vaccine for intramuscular use and that the product is preservative free and does not contain any thimerosol. Your internist also provided counseling regarding the uses of the vaccine and discussed adverse effects.

What to report: You have four code choices (90655-90658) for a trivalent split virus vaccine administered intramuscularly. Since your internist administered a preservative free dose, you will narrow your choice to reporting two codes. Since the age of the child is between 6-35 months, you will have to report 90655 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use). Since your internist also counseled about the vaccine, you’ll have to use the CPT® code 90460 to report the administration.

Look at Vaccine Brand For Medicare Patients

If your internist is providing the influenza vaccine to a Medicare patient, you will have to look specifically into the brand of vaccine as the codes you use may be different depending on the vaccine used. So when reporting the vaccine for Medicare patients, you can also choose from the following codes:

• Q2033 -- Influenza vaccine, recombinant hemagglutinin antigens, for intramuscular use [Flublok]
  
• 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 -- …[Flulaval]
  
• Q2037 -- …[Fluvirin]
  
• Q2038 -- …[Fluzone]
  
• Q2039 -- …[not otherwise specified]
  

“You also need to remember that the influenza administration code is different for Medicare,” adds Moore. “Specifically, you should report G0008 (Administration of influenza virus vaccine) when billing Medicare.”