Internal Medicine Coding Alert

G codes rule Medicare admin; others prefer CPT codes.

Remember the different reporting rules for Medicare and private payers, or denials for your internist's vaccination services could leave you feeling queasy. Check out this primer on separating the coding rules for flu vaccinations.

When reporting the flu vaccine supply, choose from either 90656 (Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use) or 90658 (Influenza virus vaccine, split virus,

when administered to individuals 3 years and older, for intramuscular use), confirms Deb Chandler, BA, CPC, ACS-FP, CCP, with FPA in Columbus, Ohio.

You'll use 90656 for vaccines without preservatives, and 90658 when the vaccines contain preservatives, Chandler says.

How to tell: Check the packaging on the vaccine, recommends Jan Allen, claims and accounts receivable manager for a four-physician practice in Santa Paula, Calif. "The insert [in the package] states whether it has a preservative," she says.

If the packaging does not help, contact the manufacturer and ask if the vaccine contains preservatives. Then, make sure other coders and physicians know which vaccines contain preservatives and which do not.

The patient's payer is not an issue when selecting flu vaccine supply codes, but you'll have to know the insurer to select the correct administration code. For Medicare payers, and payers that follow Medicare rules, you'll report G0008

(Administration of influenza virus vaccine) for the administration, says Stacie Krase, billing specialist at Northern Lake Medical in Gurnee, Ill.

Example: A 73-year-old Medicare patient reports to the internist for a scheduled flu shot. The internist provides the preservative-free immunization. In this instance, report 90656 and G0008.

When you provide the same service to a patient with commercial insurance, you'd report 90656 for the supply and 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]

;one vaccine [single or combination vaccine/toxoid]) for the administration -- if the flu vaccine is the only injection of the encounter.

Medicare and private payers also have differing coding conventions for encounters in which your internist provides a flu vaccine and another vaccine during the same encounter.

The most common multiple-immunization scenario for most internal medicine practices is the flu/pneumonia vaccine combination, Chandler reports. If the internist provides these vaccines to a patient with private insurance, report the following:

• 90656 or 90658 for the flu vaccine supply for intramuscular use

• 90471 for the flu vaccine administration

• 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use) for the pneumonia vaccine supply

• +90472 (... each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]) for the pneumonia vaccine administration.

But for a Medicare payer, you'd report the same multi-shot scenario thusly:

• 90656 or 90658 for the flu vaccine supply for intramuscular use

• G0008 for the flu vaccine administration

• 90732 for the pneumonia vaccine supply

• G0009 (Administration of pneumococcal vaccine) for the pneumonia vaccine administration.

Note: Medicare also has an administration code for hepatitis B vaccine; use G0010 (Administration of hepatitis B vaccine) for the administration of this vaccine. For private insurers, stick with +90472 for the administration of any

subsequent vaccines, reports Sheila Dullum, CPC, coder at Meriter Medical Clinic in Middleton, Wis.For example, if the internist administers three immunizations during the same session for a non-Medicare patient, report 90471 and

+90472 x 2, Dullum explains.

Remember, it is possible for your internist to provide a flu immunization to a patient intranasally; when this occurs, you need to be ready to adjust your coding.

Supply: Rather than 90656 or 90658, you'll code intranasal vaccine supply with 90660 (Influenza virus vaccine, live, for intranasal use), regardless of payer, relays Allen.

Admin: Report intranasal vaccine administration with 90473 (Immunization administration by intranasal or oral route; one vaccine [single or combination vaccine/toxoid]) for private payers; for Medicare stick with G0008.

You should use G0008 "because the definition in the HCPCS manual is simply 'administration of the flu vaccine'; it doesn't give a specific route for this administration," Chandler explains.

For the majority of your flu shot claims, V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza) is the only diagnosis code you'll need.

However, there are encounters in which you should select a different ICD-9 code, says Chandler.

"If a flu vaccine and pneumonia vaccine are given at the same encounter, the diagnosis code changes to V06.6 (Need for prophylactic vaccination and inoculation against combinations of diseases; streptoccocus pneumonaie

 [pneumococcus] and influenza)," she says. "This is a combination ICD-9 code. Other than in that instance, V04.81 is the appropriate diagnosis code for flu vaccines."

So let's say the internist provides a preservative-free flu vaccine injection and a pneumonia vaccine, to the same Medicare patient during the same encounter. On the claim, you'd report the following:

• 90656 and G0008 for the flu vaccine supply and administration

• 90732 and G0009 for the pneumonia vaccine supply and administration

• V06.6 appended to 90656, G0008, 90732, and G0009.