Medicare Compliance & Reimbursement

Question: We have begun administering Flumist along with well checks and other immunizations. For the administration code of FluMist, denials are coming in that state "90473 cannot be billed with 90471 or 90472." Is there a better way to code the administration? Has anyone else had this issue yet?

Answer: Codes 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) and 90473 (Immunization administration by intranasal or oral route; one vaccine [single or combination vaccine/toxoid]) are for initial immunization administration.

Problem: You cannot report both together. "Do not report 90473 in conjunction with 90471," according to CPT's parenthetical instruction after 90473.

Better way: You indicate that you are administering FluMist in addition to other immunizations. When giving intranasal and injectable vaccines, you should report the shots before the inhaled administration.

For instance, you would code the administration of two vaccine injections plus FluMist with codes 90471, +90472 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]), and +90474 (Immunization administration by intranasal or oral route; each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]).

Why: The Medicare Physician Fee Schedule assigns 0.56 relative value units to 90471 and 0.36 to 90473 in 2008. Payers may similarly pay more for the injected product administration. If an insurer's policy applies payment reductions, bundles, or frequency limits to additional administrations (90472 has 0.29 RVUs, whereas 90474 contains 0.25), it's better to have the initial higher-paying vaccine administration (90471) paid off the bat and then appeal incorrect rejections.

Pay attention: The insurer denial statement, "90473 cannot be billed with ... 90472," encourages listing vaccine administration codes using this more pay-producing order. CPT does permit 90472 in conjunction with 90473. But this would result in less pay than 90471, 90474.