Pediatric Coding Alert

Focus on 2 details to capture the flu vaccine pay you deserve

If you're losing money on flu product, you're coding could be to blame.

Each influenza virus vaccine has a unique code, says Joel Bradley Jr., MD, FAAP, a member of the AMA CPT Editorial Panel. So you have to pay attention to the details.

Why: If you code a regular product when you should have coded a preservative-free vaccine, you stand to lose about $9*. We all know that every penny counts, especially when it comes to vaccine product payment. Here's how to fix the problem as flu shot season gets under way.

* Note: Prices are based on Medicare Part B's payment allowances for the influenza virus vaccine when payment is based on 95 percent of the average wholesale price (AWP).

Look at Age When Choosing Code

Make sure to check a patient's age when assigning an intramuscular flu vaccine code. The dose changes at age 3,  Bradley says. So the codes have different payment rates to reflect that.

Check it out: Code 90658 (Influenza virus vaccine, split virus, when administered to 3 years of age and older, for intramuscular use) pays double the rate of 90657 (Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use). So if a nurse administers Fluzone to a 4-year-old asthmatic, and you incorrectly choose 90657, you are paid $6.31--a loss of more than $6. Because the child is older than 35 months, you should have reported 90658 and received $12.62.

Zoom In on Product Specifics

Find out if your practice uses flu vaccine with no preservative. Patients are becoming more discerning when choosing a vaccine, so more of them request the preservative-free vaccine, says Karen Deardurff, CPC, coder at Saint Joseph Physician Network in Mishawaka, Ind.

Must know: CPT has different codes for regular and preservative-free product. "Preservative-free products are more expensive, so make sure to use those specific codes for that product," Bradley says.

Reality: If you report the regular code for flu vaccine administered to a baby when you actually gave a preservative-free product, you'll cut $9.07 from your pay. The preservative-free pediatric code (90655, Influenza virus vaccine, split virus, preservative-free, when administered to children 6-35 months of age, for intramuscular use) pays $15.38 compared to $6.31 for the regular product code (90657).

And if you're not getting paid more for the preservative-free product and you're required to use it, make a complaint. Go to the insurer and explain that "the state requires us to use this product, so we need to be paid appropriately for using it," Bradley says.