Pediatric Coding Alert

Swine flu has made an early arrival in several states and in your 2009 preventive and sick coding. To avoid denials for H1N1 vaccination administration, you're going to have to check which of three administration code options your major payers want. "Some payers want you to use the new code, others want you to use Medicare's code, and others want you to use the regular vaccine administration codes," says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Best bet: Create an Excel spreadsheet that lists which H1N1 vaccine administration code each of your payers requires. Here are the options.

The AMA fast-tracked a CPT code for vaccine administration specifically for H1N1, Tuck says. Code 90470 (H1N1 immunization administration [intramuscular] [intranasal] including counseling when performed]) is effective immediately.

In addition, CPT revised the existing product code from a generic pandemic code to specify H1N1. Revised code 90663 will now read "Influenza virus vaccine, pandemic formulation, H1N1." The revision adds "H1N1" to the descriptor shown in your CPT 2009 manual.

"The new CPT code will streamline reporting and the reimbursement procedure for physicians and health care providers who are expected to administer nearly 200 million doses of the H1N1 vaccine in the United States," announced the AMA in "CPT Codes for 2009 H1N1 Influenza Immunizations" (www.ama-assn.org/ama/pub/h1n1/resources/cpt-codes.shtml). "The codes will also help to efficiently report and track immunization and counseling services related to the H1N1 vaccine throughout the health care system."

To muddy the waters, Medicare had already created G9141 (Influenza A [H1N1] immunization administration [includes the physician counseling the patient/family])."Medicare had established the precedent for a specific code for H1N1 administration with its own G code," Tuck notes.

Usually pediatric practices can disregard Medicare's G codes as they are specific to billing Medicare carriers. "But some payers are saying to use G9141" (based on the information available at the time of publishing),

Tuck reports. For instance, Wellcare's Sept. 30 H1N1 Vaccination Update instructs providers to use G9141 for immunization administration to Medicaid members.

For other insurers, you can turn to more familiar choices. Some payers want you to keep using the general vaccine administration codes 90465-90474 (Immunization Administration for Vaccines/Toxoids).

One thing will be standard across the board: You should bill 90663 for the 2009 H1N1 vaccine should at zero dollars, since the federal government is providing the vaccine free of charge, instructs the AMA release.

Do this: You should charge for the administration with 90470, G9141, or 90465-90474. For Medicaid or Vaccines for Children (VFC), the amount can be no higher than your state's specific allowable for vaccine administration.

"This is generally $16-$20 depending on the state," says Tuck. For private payers, "payments will be based on the contracted rate with the carrier," states the American Academy of Pediatrics.

There are currently no relative value units assigned to 90470. CMS plans on publishing rates for the code in the November 2009 Federal Register for the 2010 Medicare Physician Fee Schedule.

"Max has confirmed H1N1, but no lab was done," gossips the mom at school. Does that mean the pediatrician reported 488.1?

Just because ICD-9 2010 provides a code for H1N1 doesn't mean you should automatically use it. The 2009 coding guidelines instruct you to code only confirmed cases of novel H1N1 influenza virus (H1N1 or swine flu, code 488.1). "This is an exception to the hospital inpatient guidelines (Section II, H) (Uncertain Diagnosis)," state the 2009 ICD-CM Official Guidelines for Coding and Reporting (www.cdc.gov/nchs/data/icd9/icdguide09.pdf).

Rule: Coding should be based on the provider's diagnostic statement that the patient has novel H1N1 (H1N1 or swine flu) influenza. "In this context, 'confirmation' does not require documentation of positive laboratory testing specific for novel H1N1 influenza," according to the guidelines.

If the provider records "suspected or possible or probable novel H1N1 influenza (H1N1 or swine flu)," do not assign 488.1. Instead, you should use the appropriate influenza code from category 487.x. "Some practices do not have the testing available, so they cannot conclude that the patient has H1N1 influenza and cannot code the condition as 488.1," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. For instance, some Florida physician offices are testing specimens for only influenza A and/or B and are not sending specimens to the state health department for H1N1 testing.

"In reality, to report a specific strain, one should have proof," says Philip Marcus, MD, at the St. Francis Hospital Heart Center in Roslyn, N.Y. "Otherwise, it's best to report influenza (487.x) and  ot speculate."

Do this: Since influenza A and B symptoms are nearly identical to the H1N1 influenza strain, consider a diagnosis of H1N1 only when other cases have been diagnosed in the area, Marcus suggests. "At the present time, there are no easy ways to decide which strain of influenza is responsible for an individual infection. In fact, with the recent outbreak of H1N1 infection, most of the presumed cases were indeed negative when specifically tested for H1N1 antigen," he says.