Practice Management Alert

4-Step plan shines light on billing

It's flu season, and medical offices may feel they-re ready for the rush of patients wanting influenza vaccines. But billing for flu shots is not as simple as it may seem.

To ensure the claim's success, billers need to know what type of influenza vaccine the doctor used on the patient, the patient's age, and the number of injections the doctor gave during the encounter. Failure to secure accurate information in these categories could lead to bumps in the road to payment and may even result in denial of the flu-shot claim.

Billers can fight potential snafus on flu-shot claims by following these steps:

Identify Patient Age, Vaccine Type

When selecting an injection vaccine code, it is important to know the age of the patient, says Susan Pincus, CPC, CHC, an independent healthcare consultant in Atlanta. When a patient is under 3 years old, you-ll use one of two codes for the vaccine:

- 90655--Influenza virus vaccine, split virus, preservative-free, for children 6-35 months of age, for intramuscular use

- 90657--Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use.
 
For all patients 3 years old or above, you will choose from one of these codes for the injection vaccine:

- 90656--Influenza virus vaccine, split virus, preservative-free, for use in individuals 3 years of age and above, for intramuscular use

- 90658--Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use.

If you are having trouble deciding whether your vaccine has preservatives, check the packaging for clues. Vaccines with preservatives are termed -regular,- while the other vaccines are -preservative-free.-

Exception to the age rule: For intranasal vaccinations, always bill for the vaccine with 90660 (Influenza virus vaccine, live, for intranasal use). Age is not a factor.

Determine How Doctor Administered Vaccine

Once you have decided on a vaccine code, you should work toward figuring out the method your physician used to deliver the vaccine.

With private carriers, bill injection administration with 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) when the flu shot is the primary vaccine.

If your physician gives a patient a flu injection as an additional vaccine, bill +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]).

With Medicare payers, billers should use G0008 (Administration of influenza virus vaccine when no physician fee schedule service on the same day) as the vaccine delivery code, Pincus says.

Intranasal rules: A medical office reporting an intranasal flu vaccination would bill for a different administration code than 90471 or 90472.
 
For intranasal flu vaccines, bill 90473 (Immunization administration by intranasal or oral route; one vaccine [single or combination vaccine/toxoid]). When the physician gives the intranasal vaccine as an additional vaccine, bill +90474 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]).

Counseling Means Different Code

Remember, if your physician provides counseling to the patient during the vaccination encounter, and the patient is 8 years old or younger, you should choose from the pediatric-specific immunization administration (PSIA) codes, says Vickie Jackson, practice administrator for Southern Orange County Pediatrics in Lake Forest, Calif.

So if Dr. P, a pediatrician, gives a 7-year-old patient an intramuscular flu vaccine injection, and counsels the patient's mother about the shot's side effects, you would use 90465 (Immunization administration under 8 years of age [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels the patient/family; first injection [single or combination vaccine/toxoid], per day) for the session.

If your physician gives a patient a flu injection as an additional injection, bill +90466 (... each additional injection [single or combination vaccine/toxoid], per day [list separately in addition to code for primary procedure]). On the other hand, if your physician provides counseling and administers an intranasal flu virus to a 7-year-old patient, you would code:

- 90467 (Immunization administration under age 8 years [includes intranasal or oral routes of administration] when the physician counsels the patient/family; first administration [single or combination vaccine/toxoid], per day).

- Code +90468 (... each additional administration [single or combination vaccine/toxoid], per day [list separately in addition to code for primary procedure]) is for additional injections.)

Apply Diagnosis Code
 
All flu-shot claims should include the ICD-9 code V04.81 (Need for prophylactic vaccination against certain viral diseases; other viral diseases; influenza),  Pincus says. Without this V code, your claim stands a chance of rejection. Also, the flu shot is covered once each flu season for most patients, Pincus says.