Internal Medicine Coding Alert

Question: The internist's physician assistant (PA) performed a level-one E/M service for a new Medicare patient to address her asthma-related issues, then administered a preservative-free intramuscular flu vaccine (without pneumonia vaccine). How should I code this encounter?

Connecticut Subscriber

Answer: It is very important to check whether the vaccine had preservatives before coding. You should report 90656 (Influenza virus vaccine, split virus, preservative-free, when administered to individuals 3 years of age and older, for intramuscular use) for preservative-free vaccines, and 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) for supplies with preservatives. Patients who require flu vaccinations from your internist will allow you to report a pair of codes for the service: one for the vaccine, and another for the administration. In addition, you should be able to report a separate E/M because the NP addressed the patient's asthma problem.

But your coding will change based on the patient's insurer. For Medicare patients, report the following:

• 90656 for the vaccine (but only if the physician practice purchased the product for the patient)

• G0008 (Administration of influenza virus vaccine) for the administration

• V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza) linked to G0008 and 90656 to provide medical necessity

• 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; straightforward medical decision-making) for the E/M

• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99201 to show that the vaccination and E/M were separate services

• 493.90 (Asthma, unspecified) linked to 99201 to represent the patient's asthma.

Commercial payers: To report the same service to a private insurer, drop G0008 and instead report 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the administration. Also, remember to report:

• 90656 with V04.81 appended for the vaccine

• 99201 with modifier 25 appended to show that the vaccination and E/M were separate services.

Note: Some private payers will cover the flu vaccine only for those patients who are at greater risk for contracting the flu (for instance, asthmatics). In this case, you must link 493.90 to 90656 in addition to V04.81.