Otolaryngology Coding Alert

Question: Some patients are requesting the H1N1 flu vaccine this fall. What product code would we use?

New York Subscriber

Answer: It depends on the patient's insurer. The AMA recently confirmed the CPT code to use, but Medicare released its own G codes for the swine flu's vaccine and administration. Here's how to code using both guidelines.

Private payers: You would report the H1N1 flu product with the general pandemic vaccine code 90663 (Influenza virus vaccine, pandemic formulation), according to an AMA CPT Category 1 Vaccine Codes clarification. "The appropriate immunization administration code (90465-90474) may be reported in conjunction with 90663 for the administration of the vaccine, depending on the route of administration and the age of the patient," states the update (www.amaassn.org/ama1/pub/upload/mm/362/vaccine-codes.pdf).

Beware: The Federal Drug Administration has not yet approved the swine flu vaccine, which is not included in the traditional influenza vaccines. Therefore, 90663 is not listed on the 2009 Average Sales Price File.

Medicare carriers: CMS introduces two new codes that apply to the H1N1 vaccine, as follows:

• G9141 -- Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

• G9142 -- Influenza A (H1N1) vaccine, any route of administration.

Because the H1N1 vaccine will generally be available to providers free of charge, do not bill Medicare for the vaccine -- only for the administration, said CMS's Stewart Streimer during an Aug. 25 CMS Open Door Forum. Report one unit of G9141 for each administration of the H1N1 vaccine, according to CMS (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6617.pdf).

CMS intends to pay you the same amount for G9141as it reimburses for other vaccine administration codes G0008 (Administration of influenza virus vaccine) and G0009 (Administration of pneumococcal vaccine). "The reimbursement varies by state, but ranges from about $18 to $25," says Jay Neal, a coding consultant in Atlanta. Find your state's rate at www.cms.hhs.gov/AdultImmunizations/Downloads/AdminRates09.pdf.

Bonus: Although Medicare normally pays for just one vaccination per year, it will pay for both a seasonal flu vaccine and an H1N1 vaccine if both are medically necessary, according to a Sept. 2 e-mail from CMS to all fee-for-service providers.