Internal Medicine Coding Alert

The beginning of fall signals the start of the influenza vaccination season. Due to recent revisions in Medicare policy, many patients also may be requesting a pneumococcal pneumonia vaccine (PPV) from their internist when they receive their flu shots. Although Medicare reimburses for the administration of both vaccines, whether an office visit also may be billed will vary among the local Medicare carriers.

According to the most recent data available from the Health Care Financing Administration (HCFA), 65 percent of eligible Medicare beneficiaries received an influenza vaccination in 1996. The administration, however, is aiming to raise that figure to 72 percent for the 2000-2001 flu and pneumonia season through a series of ads and brochures that explain that the vaccine is available to all beneficiaries upon request without a physicians order and without physician supervision.

Once a Season Is Not Once a Year

Although the flu vaccine typically is administered annually during the fall or winter, beneficiaries conceivably could receive more than one injection per year. Most patients will receive one flu vaccination per season, but that doesnt mean they have to wait 12 months between vaccinations, says Brett Baker, third-party relations specialist at the American Society of Internal Medicine. They could receive the vaccine in December one year and October the next. Some local carriers may even allow more than one vaccination per season if there is medical necessity.

The following CPT codes can be used to bill the vaccine:

90657 influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use

90658 influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use

90659 influenza virus vaccine, whole virus, for intramuscular or jet injection use

In addition to the vaccine, internists also can bill for the administration of the vaccine using G0008 (administration of influenza virus vaccine when no physician fee schedule service on the same day). The appropriate diagnosis code is V04.8 (need for prophylactic vaccination and inoculation against certain viral diseases; influenza).

No Physician Order for PPV Vaccine

Compared to the number of people who received flu vaccinations, a smaller portion (44 percent) of the Medicare population has received a PPV immunization, which is recommended by the Centers for Disease Control for adults age 65 or older. As part of its plan to increase the level of PPV immunization to 55 percent of the Medicare population by the end of fiscal year 2001, HCFA eliminated, effective July 1, 2000, the requirement that the PPV immunization be ordered and supervised by a physician. Although patients usually need only one PPV immunization in their lifetime, internists no longer need to provide the patient with a record of the injection.

This revision makes the PPV immunization more accessible to Medicare beneficiaries, explains Baker. Now patients can request it from their internists and no longer have to be at high risk to obtain it.

Code 90732 (pneumococcal polysaccharide vaccine, 23-valent, adult dosage, for subcutaneous or intramuscular use) should be used to report the vaccine. Internists also may bill for the administration of the vaccine with G0009 (administration of pneumococcal vaccine when no physician fee schedule service on the same day). The appropriate diagnosis code is V03.82 (need for prophylactic vaccination and inoculation against bacterial diseases; streptococcus pneumonia [pneumococcus]).

Some Carriers Pay for Additional Office Visit

According to Baker, for reimbursement of an evaluation and management (E/M) service in addition to the administration of both vaccines, there will be some variation between the national policy and what the local carrier allows. Baker points out that section 4480.1 of the Medicare Carriers Manual permits additional reimbursement if the office visit was incurred for reasonable and necessary services in addition to the vaccination.

The actual HCPCS descriptor, however, is less concrete and gives the carrier discretion regarding whether or not to cover the flu vaccine administration when its provided on the same date as an office visit, Baker says.

Many carriers will pay for the office visit if there is a separate, medically necessary reason for the service. According to a bulletin dated October 1999 issued by the New Jersey Medicare carrier, Empire Medicare Services, HCPCS code G0008 may be paid in addition to other services, including evaluation and management services. In this situation, many carriers will require the attachment of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the office visit code.

On the other hand, according to the June 2000 Medicare Bulletin issued by National Heritage Insurance Company, one of the Medicare Part B Carriers for California, it is inappropriate to bill G0008 and G0009 in addition to a same-day physician fee schedule service, such as an office or other outpatient visit.

The only way to be sure about whether a local carrier will reimburse for the additional office visit is to check with the carrier directly. Announcements regarding influenza and PPV vaccination policies frequently are printed in local Medicare bulletins in the fall.