Pediatric Coding Alert
These 5 Tips Will Help You Collect for Flu Visits This Season
It’s that time of year again—when parents present to the office requesting flu shots for their children or evaluations of possible flu diagnoses. Although some influenza visits are fairly straightforward, chances are strong that you’ll have a few questions about how to appropriately collect for your flu shot and flu diagnosis services. The following five tips can help you eliminate payment woes before they begin.
Tip 1: Two Strains Could Equal Dual Codes
Performing a flu test is standard practice for pediatricians, but when you have to administer two tests on the same date, your coding can get tricky. If you perform a rapid flu test for strains A and B at the same visit, many insurers will allow you to report 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; influenza) twice.
Some Medicaid states require you to follow Medicare modifier guidelines and append modifier QW (CLIA-waived test) to 87804. To keep coding uniform, many practices use modifier QW regardless of payer.
If you use a product that differentiates between influenza A and B and the physician documents both results, you should report 87804 twice. Many carriers allow you to report 87804 x 2 without a problem, because the MUEs (medically unlikely edits) that Medicaid and some other payers utilize to auto-deny second and subsequent line items limits you to two units of 87804. This means that your carrier will process two units of the code but would most likely auto-deny three or more units billed together.
For payers that do not recognize two units of 87804 and deny the second charge as a duplicate, use modifier 59 (Distinct procedural service) on the second 87804 entry. This modifier indicates that a different test was performed to test for a distinct strain. Therefore, you would report 87804-QW with one unit and 87804-59 for the second unit to these insurers.
Why not 91? In some rare cases such as certain state Medicaid providers, you may be advised by your payer to use modifier 91 (Repeat clinical diagnostic laboratory test) on the second listing of 87804. However, before using this coding method, which contradicts current coding guidelines, obtain a written recommendation from the payer.
The May 2009 CPT® Assistant backs up the advice that modifier 59 is a better option than modifier 91, stating, “Use modifier 59 when separate results are reported for different species or strains that are described by the same CPT® code. This advice should serve to clarify the use of the modifier in these instances. As a matter of differentiation, modifier 91 is used when, in the course of treating a patient, it is necessary to repeat the same laboratory test on the same day to obtain subsequent test results.”
Tip 2: E/M With Flu Shot Requires Modifier
Although most of your flu shot visits involve just a few minutes of the doctor’s time, you’ll also experience scenarios when the doctor has to perform a separate, complete E/M visit in addition to the flu shot. In these cases, a modifier will be your friend.
Here’s why: According to Correct Coding Initiative (CCI) edits, E/M office or inpatient codes are bundled into the vaccine administration codes 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered), 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) and 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]).
The modifier indicator for most of these bundles is “1,” which indicates that you can separate the codes using an appropriate modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). However, the exception to this rule is code 99211. The modifier indicator for the edits that bundle this code with the vaccine administration codes above is “0.” That means CCI edits won’t allow you to report 99211 for the same patient on the same date as a vaccine administration.
Note: You should not report an E/M visit code if your doctor only counsels on the vaccine (recording a brief history, ruling out any contraindications to the administration of the vaccine and counseling on the vaccine). When the nurse does the same service, such a minimal assessment is likely to be considered part of the vaccine administration itself, which may explain why the CCI edits do not allow you to report 99211 in addition to a vaccine administration code. In such a case, you will only report the administration code and not an E/M code. You can report an E/M service with a vaccine administration code if and only if the E/M service was significant and separately identifiable from the vaccine administration as reflected in the physician’s documentation of the encounter.
As noted, you need to have proper documentation to justify the medical necessity and to prove that your physician actually provided a distinctly separate E/M service while also giving the patient a flu shot. In such a case, a different diagnosis code may help support separate payment of the office visit code. In any case, ICD-9 code V04.81 (Need for prophylactic vaccination and inoculation against other viral diseases; influenza) is linked to the code for the influenza administration as well as the CPT® code for the influenza vaccine itself, which you should also report. If you are using ICD-10 codes, you will have to use Z23 (Encounter for immunization) instead of V04.81.
Tip 3: Half-Dose of Vaccine May Require Second Visit
When your pediatrician administers a low dose of the flu vaccine, you’ll face several options for coding the claim. Which one you choose could just come down to the patient’s age and the reason for the decreased dosage.
Younger children (under the age of three) typically get what could be considered a half dose of the vaccine, but there is a code specifically created for that purpose. You’ll report 90655 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use) for this vaccine administration. The child will get a booster one or two months later.
If, however, the child is older than three and the pediatrician administers a half dose, you should bill a full dose only once—either on the first visit or the second one—but don’t bill twice.
Tip 4: Avoid 90662 for Pediatric Patients
When you administer Fluzone, you might just reach for 90662—but this code is typically inappropriate for pediatric patients, and could prompt quick denials.
Most payers will only cover 90662 (Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use) for patients age 65 and older. The higher antigen content offers increased protection to older patients, and this code is considered a high dosage of the Fluzone vaccine because it contains four times the hemagglutinin antigen per influenza strain than traditional influenza vaccines.
This vaccine may also be appropriate for people with impaired immune responsiveness, who may benefit from an increased antigen dose to more effectively stimulate the needed immune response. If that is the case with a pediatric patient and the insurer denies it, have the physician write an appeal letter to the payer explaining the unique circumstances under which he administered the Fluzone shot and why the high dose was required for your particular patient.
If your pediatric patient was not immunocompromised, you should not report 90662 for Fluzone. In healthy, younger patients, the doctor would typically administer only a standard dosage of the drug, which you would typically report with 90657 (Influenza virus vaccine, trivalent, split virus, when administered to children 6-35 months of age, for intrmuscular use) or 90658 (Influenza virus vaccine, trivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use), depending on the patient’s age, if the pediatrician uses the version with preservatives.
For the preservative-free vaccines, you’d choose either 90655 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use) or 90656 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to 3 years of age and older, for intramuscular use).
Tip 5: Look to J10 and J11 for Flu Dx in October
You may have the ICD-9 codes for influenza committed to memory, but like all of your other diagnosis codes, you’ll have to replace them effective Oct. 1, when ICD-10 goes into effect.
Current way: When reporting a diagnosis of influenza, you currently start with 487 (Influenza caused by unspecified influenza virus) and, depending on symptoms and other manifestations, apply a 4th digit as follows:
The 487 series is also used with seasonal influenza viruses. If you know the influenza is due to certain identified influenza viruses, you may need to look at the 488 series in ICD-9. That series is also divided into three categories, based on the 4th digit, and each also requires a 5th digit. The 4th digit categories in this series are:
The fifth digit options in each of these categories are the same, and they generally parallel the fourth digits in the 487 series, namely:
ICD-10: When ICD-10 goes into effect, 487 under ICD-9 will crosswalk to J10 (Influenza due to other identified influenza virus) and J11 (Influenza due to unidentified influenza virus). As with ICD-9, both J10 and J11 further expand into a fourth digit classification based on the presence or absence of pneumonia, other respiratory manifestations (such as laryngitis, pharyngitis, and upper respiratory infections), gastrointestinal manifestations, or other manifestations such as encephalopathy, myocarditis, or otitis media.
You’ll identify other manifestations such as encephalopathy, otitis media or myocarditis, with a fifth digit. Like the 487 series in ICD-9, J10 and J11 include seasonal influenza viruses.
For example, J10 under ICD-10 expands into the following four codes using a fourth digit expansion:
J10.0 further expands into the following three codes using a 5th digit expansion based on the type of pneumonia involved:
J10.8 further expands into the following four codes using a 5th digit expansion based on the type of manifestation:
Red flag: Do not use the J10 series unless the physician has definitively identified the type of influenza virus. If it is not identified use the J11 series. The J11 series also expands using a fourth digit expansion into four codes while J11.0 and J11.8 expand using a fifth digit expansion, similar to the expansion of J10.0 and J10.8 mentioned above.
The 488 series in ICD-9 is traceable to J09 in ICD-10. There are four codes in that category:
Many of the codes in the J09, J10, and J11 series require you to use an additional code or “code also,” if applicable. For example, with J10, you are to use an additional code from the B97.- series to identify the virus in question. Be sure to pay attention to these instructions, where applicable.
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