Pediatric Coding Alert

Question: We have been getting numerous National Drug Code (NDC) denials for administering Fluzone^®. I have double-checked that the NDC code on the side of the vials - 49281-417-88 - is correct, so what am I doing wrong?

Codify Subscriber

Answer: The American Academy of Pediatrics (AAP) has provided a handy checklist of items to use for accurate medication and vaccine billing. You need to document:

1. The applicable HCPCS or CPT^® code;
2. Number of HCPCS code or CPT^® code units;
3. 11-digit NDC(s), including the N4 qualifier (which indicate the use of the NDC);
4. Dosage unit of measurement; and
5. Number of NDC units dispensed (must be greater than 0).

(Source: http://www.aappublications.org/news/2016/04/21/Coding042116.)

Based on this, and assuming that your pediatrician gave the vaccine with counseling to a patient between the ages of 6 months and 18 years during a well-child visit, the correct way to bill for Fluzone® should be as follows:

1. 90686 (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use) linked to Z23 (Encounter for immunization) and 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) linked to Z00.129 (Encounter for routine child health examination without abnormal findings) with modifier 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) appended.
2. 1 unit each of 90686 and 90460
3. N4-49281-0417-50
4. 0.5 mL
5. 1 unit

You should note that the correct way to write the NDC code for Fluzone^® for billing purposes is to add the qualifier N4 along with a leading zero to the middle section, which converts the NDC number to the preferred 11-digit format. You should also note that the NDC code is the one found on the package (49281-417-50). The number you used, which caused the denial, was for an individual syringe within the package of 10.

(Source: Sanofi Pasteur Fluzone^®, Influenza Vaccines 2017-2018 Coding and Billing Quick Reference (https://www.besse.com/BesseMedical/media/BesseMediaLibrary/pdfs/MKT30571-1-2R-Fluzone-Reimbursement-Coding-Guide-Final.pdf)).

To look up the NDC codes for other vaccines and medicines, go to https://www.accessdata.fda.gov/scripts/cder/ndc/default.cfm.