Primary Care Coding Alert

With three H1N1 administration code possibilities, you've got to get the lowdown on insurers' guidelines -- or risk rejections.

The production of effective vaccines has been identified by the U.S. health authorities as vital to ensure protection for the general population. Consequently, several vaccine manufacturers got approval from the Food and Drug Administration (FDA) for four novel vaccines against H1N1:

o Influenza A (H1N1) 2009 Monovalent Vaccine (CSL Limited)

o Influenza A (H1N1) 2009 Monovalent Vaccine (Novartis Vaccines and Diagnostics Limited)

o Influenza A (H1N1) 2009 Monovalent Vaccine (Sanofi Pasteur, Inc.)

o Influenza A (H1N1) 2009 Monovalent Vaccine (MedImmune LLC).

Medicare will cover H1N1 virus vaccine for Medicare Part B beneficiaries as an additional preventive immunization service and the administration of the H1N1 vaccine. To facilitate reimbursement for this, CMS has created two new HCPCS codes for H1N1, effective for dates of service on and after Sept. 1, 2009:

• G9141 --" Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

• G9142 --" Influenza A (H1N1) vaccine, any route of administration.

According to the MLN Matters SE0920, payment will be similar to the administration of the seasonal influenza vaccine. Medicare will pay G9141 with V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases; influenza) at the same rate established for G0008 (Administration of influenza virus vaccine).

Warning: Do not file claims for G9142. "Since the H1N1 vaccine will be made available at no cost to providers, Medicare will not pay providers for the vaccine," states MLN Matters SE0920 (www.cms.hhs.gov/MLNMattersArticles/downloads/se0920.pdf). Furthermore, don't bill Medicare an E/M service (such as 99201-99215, Office or Other Outpatient Services) if the sole purpose of the visit was to administer the vaccine. "Payment will not be made to providers for office visits when the only purpose of the visit is to administer either the seasonal and/or the H1N1 vaccine(s)," according to the article.

The AMA has also issued a new CPT code specific to H1N1 vaccine administration and revised an existing code to include the H1N1 vaccine. The codes are:

• 90470 --" H1N1 immunization administration (intramuscular, intranasal), including counseling when performed

• 90663 --" Influenza virus vaccine, pandemic formulation.

These codes are effective immediately. In addition, AMA gives specific instructions to use code 90663 in conjunction with 90470. Code 90663 should be billed for $0, since the vaccine is provided free of charge by the federal government. Providers may charge for the H1N1 vaccine administration.

Some commercial payers may accept G9141 while others use the specific CPT code or the appropriate CPT administration code based on the age of the patient and the method of administration (90465-+90474, Immunization Administration of Vaccines/Toxoids), says Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA, practice manager at American Health Information in Chicago. Since companies have unique guidelines, know your insurers' protocols.

Be proactive and start calling each payer to find out which ones are using Medicare's codes or the new or existing CPT codes, recommends Kathleen Goodwin, CPC, coding coordinator for LaPorte Regional Physician Network in Indiana.

Finally, when administering the H1N1 vaccine whether you're billing Medicare or a private insurer, all services should show the diagnosis as V04.81 for a prophylactic vaccination against influenza.

Be careful not to use 488.1 (Influenza due to identified novel H1N1 influenza virus). This diagnosis code is for patients who have confirmed cases of novel H1N1 influenza virus, not for patients receiving preventive care.