Internal Medicine Coding Alert

Here's why charging for the vaccine supply will get the feds hot.

Swine flu has swept into several states even earlier than expected, leaving coders scrambling for answers on how -- and what -- they should report when the internist administers a vaccine to combat the virus.

The lowdown: There's no getting around it; you're going to have to check which of three administration code options each of your major payers wants in order to remain compliant.

Some payers want you to use the new CPT code, others want you to use Medicare's new code, and others might want you to use the regular vaccine administration codes, says Richard Tuck, MD, FAAP, at PrimeCare of Southeastern Ohio in Zanesville.

Best bet: Create an Excel spreadsheet that lists which H1N1 vaccine administration code each of your payers requires. Here are the options.

The AMA fast-tracked a CPT code for vaccine administration specifically for H1N1, Tuck says. Code 90470 (H1N1 immunization administration [intramuscular] [intranasal] including counseling when performed]) is effective immediately.

In addition, CPT revised the existing product code from a generic pandemic code to specify H1N1. Revised code 90663 will now read "Influenza virus vaccine, pandemic formulation, H1N1." The revision adds "H1N1" to the descriptor shown in your CPT 2009 manual.

"The new CPT code will streamline reporting and the reimbursement procedure for physicians and health care providers who are expected to administer nearly 200 million doses of the H1N1 vaccine in the United States," announced the AMA in CPT Codes for 2009 H1N1 Influenza Immunizations (www.ama-assn.org/ama/pub/h1n1/resources/cpt-codes.shtml).

"The codes will also help to efficiently report and track immunization and counseling services related to the H1N1 vaccine throughout the health care system," the release states.

Medicare providers will want you to use new G code G9141 (Influenza A [H1N1] immunization administration [includes the physician counseling the patient/family]), confirms Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Check out Medicare's latest MLN Matters article on H1N1 for more information at: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0920.pdf.

Payment for G9141 will mirror the rate for G0008 (Administration of influenza virus vaccine), says Alan Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. This means between $18-$25 per H1N1 administration.

"Since the vaccine has just hit the providers, no one has any experience yet. ... The $18-$25 range is what Medicare has reimbursed in the past [for G0008]," Plummer says.

Dx alert: H1N1 administration claims will be processed using the diagnosis V04.81 (Need for prophy-lactic vaccination and inoculation against certain diseases; influenza).

You can, but you won't get paid for it. Medicare also created G9142 (Influenza A [H1N1] vaccine, any route of administration) to represent the vaccine supply.

The catch: "Since the vaccine has been purchased by the government and given to the medical providers, no charge for the vaccine should be made," cautions Plummer. "This needs to be emphasized."

So if you do code G9142 for tracking purposes, be sure to mark it as $0 until the practice starts paying for the vaccine. If G9142 appears on the claim this way, only the claim line will be denied.

If you are using CPT codes and decide to code for the vaccine, the AMA also instructs you to code 90663 (Influenza virus vaccine, pandemic formulation) at $0, according to its release.

Not necessarily. Many of the larger payers are accepting either G9141 or 90470 for the vaccine administration, Pohlig points out.

"Blue Cross/Blue Shield is accepting either G9141 or 90470," Pohlig says. Humana, Cigna, and Aetna will also allow either administration code, according to the American Academy of Family Physicians (www.aafp.org/online/en/home/practicemgt/codingresources/h1n1admincoding.html).

Bright idea: "Some practices are making it easy and intend to report G9141 across the spectrum of payers" that allow for either admin code, Pohlig says. Doing this could streamline your practice's H1N1 coding.

You should still check with each payer to be sure that it wants either 90470 or G9141 for the administration.

There could be some out there that will accept only 90470; and some may even want to see the old codes 90465-90474 (Immunization Administration for Vaccines/Toxoids) for the administration.