Part B Insider (Multispecialty) Coding Alert

Here’s a helpful checklist to assist with vaccine coding challenges.

It’s no fun getting sick, but it can be even less fun to code for influenza vaccinations. This important preventive measure is one of the most valuable services you can offer to your patients every flu season, but understanding the how, what, and when of flu vaccine coding is crucial to avoid a rejected claim.

Take a Look at the Seasonal Parameters

Influenza vaccinations are given per flu season and not by year, so Medicare beneficiaries can reasonably receive more than one booster a year as long as the shot is medically necessary and the documentation is in the notes, Michelle Coleman CPC, of NGS’s provider outreach and education department, indicates in a Sept. 28, 2016 web presentation. “You can receive more than one flu vaccination per year,” she explains. “The way we pay it is per season.”

Time frame. According to CMS, payments for influenza vaccinations run from Aug. 1 to July 31 each year. For example, you could administer a flu shot in February 2016, and your patient could come in again in October of 2016 for another because that is considered part of the 2016/2017 flu season.

Pricing. The Medicare Part B payment allowance is “95 percent of the average wholesale price (AWP), and the pricing is updated quarterly,” says Coleman. Here is the link to the most up-to-date 2016/2017 influenza vaccination pricing, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html.

Nonparticipant facts. A recent MLN Matters (MM 9758) from Sept. 9, 2016 reminds providers that “the annual Part B deductible and coinsurance amounts do not apply” for these vaccinations. Nonparticipating providers must take assignment on the claim as well and Coleman recommends they let their patients know ahead of time to avoid the administrative fee charged by nonparticipants. “Let your patients know upfront if you are a nonparticipating provider,” she says. “Because there are many options for beneficiaries, where they don’t have to lay out an additional fee.”

Know the Codes—Old and New

Single claims for the various flu vaccines must be submitted electronically to your MAC on the CMS-1500 form. But, there are currently ten exceptions under the Administrative Simplification Compliance Act (ASCA) that allow you to bypass the electronic form and submit a paper one. The exceptions and the explanations behind them can be found in the Medicare Claims Processing Manual with many of the special case related to the size of the practice or mass immunization issues. (https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1194CP.pdf)

Two codes for every claim. “The codes vary based on the drug manufacturer, so you’d bill according to which code is applicable to your office,” advises Coleman. It’s important to note that you will need to report two codes for each vaccination claim: one administrative code and one vaccine code.

“To administer the influenza vaccine you will use the HCPCS code G0008 (Administration of influenza virus vaccine) in addition to the CPT^® code, which is the actual vaccine itself.”

Age also factors into picture, so before you write up your claim, it’s a good idea to check the age of the patient against the CPT^® code used.

CPT^® options. Here is the complete list of CPT^® codes that apply to the typical Medicare patient, with some new additions to the offering:

• 90630- (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use)
• 90653- (Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use)
• 90656- (Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use)
• 90661- (Influenza virus vaccine (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use)
• 90662- (Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use)
• 90672- (Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use)
• 90673- (Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use)
• 90686- (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use)
• 90688- (Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to individuals 3 years of age and older, for intramuscular use)

Recently added:

• 90674- (influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunits preservative and antibiotic free, 0.5 mL dosage, for intramuscular use)   

Here are a few Q-code choices. There are three Q-codes for influenza vaccination. These HCPCS codes offer some different options for providers, but be wary of how you use Q2039 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [not otherwise specified]), warns Coleman. “To use this code [Q2039] you really need to make sure there is absolutely no other code available. Otherwise your claim will be denied,” she says.

Here are the other HCPCS alternatives:

• Q2035- (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [Afluria])
• Q2037- (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [Fluvirin])

ICD-10 tip. You will report any immunization, and that includes all influenza vaccinations, with Z23 (Encounter for immunization) as your diagnosis code.

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