Primary Care Coding Alert

It's that time of year again turkey roasting in the oven, holiday gift shopping, a crispness in the air, and the sweet sound of your office mate sneezing as she copes with the flu. Patients may be coming in droves for their annual flu shots, but you may not be getting properly paid for your services.

Although four CPT codes describe the influenza vaccine (90657-90660), FPs will mainly use 90657 (Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use) and 90658 (Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use), says Sandra Soerries, CPC, CPCH, director of Healthcare compliance services with Tait Advisory Services, a consulting firm in Kansas City, Mo.

Suppliers are not providing practices with the vaccine for the whole virus this year, so coders won't be using 90659 (Influenza virus vaccine, whole virus, for intramuscular or jet injection use), and the live virus vaccine (90660) is used rarely.

Report 90657 when administering the shot to children younger than age 3 and 90658 for adults. Because the Centers for Disease Control (CDC) came out with new guidelines recommending the vaccine for children age 6-23 months, practices may be using 90657 this season more often than in past years, says A. Clinton MacKinney, MD, MS, the AAFP representative on the AMA CPT Advisory Committee and medical director at HealthPartners Central Minnesota Clinics in St. Cloud, Minn.

Always bill an administration code with the vaccine code. CPT codes 90471-90474 specifically describe vaccine administration. Do not use any other injection codes for influenza shots. Use 90471-90474 when billing for patients covered by commercial carriers. For Medicare patients, use G0008 (Administration of influenza virus vaccine when no physician fee schedule service on the same day) instead of 90471-90474.

A major point of confusion when it comes to coding flu shots is whether to code an E/M visit as well. Do not use an E/M if the patient comes in just for a shot, but you can report it under certain circumstances if the patient receives the shot along with a separate procedure, Soerries says. Many coders report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) in addition to the flu shot codes, but this is incorrect.

"When a patient gets a Depo-provera shot, for example, the nurse has to evaluate and sometimes educate that patient. You can use the nurse-visit code in addition to injection codes for those encounters," MacKinney says. But, because the flu shot doesn't involve an additional evaluation, you can't use the nurse-visit code.

There are cases, however, when you can report an E/M with the flu-shot code. Not all patients come in just for flu shots, MacKinney says. Sometimes they come in for a physical exam or a problem visit and get the flu shot during that encounter. In such a case, report the influenza vaccine code, the administration code and the appropriate E/M code. Soerries suggests attaching modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to show payers that it is a separate service from the flu shot.

Coding is the same if the patient comes in for a flu shot and the FP discovers a problem and performs an exam flu-shot codes with the E/M and a modifier -25.

When a new patient presents for a flu shot, the physician may choose to take a new-patient history and perform an exam. But, Soerries says, payers may consider the exam as incidental to the flu shot for new patients. Use the regular flu-shot codes and inform the patient that he or she may be responsible for the exam portion of the visit.

The same rules apply to children receiving the flu vaccine. Many practices screen children for potential adverse effects before administering the shots. Most payers consider that screening to be part of the flu shot and will not reimburse separately.

When FPs just administer the flu shot, coders should report V04.8 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza). If you code an E/M visit as well, link the diagnosis code for the problem to the E/M code and link the V code to the flu-vaccine code.