Primary Care Coding Alert

Tip: Pay attention to codes with locally-controlled pricing.

CMS released its annual update to influenza vaccine payments in early October, with implementation backtracking to August 1, 2012 for any patients visiting your office. Here's your quick look at the latest pricing based on the MLN Matters article "Influenza Vaccine Payment Allowances: Annual Update for 2012-2013 Season." Now it's easy to ensure your practice files accurate claims this flu season.

Update Your Medicare Allowances

CMS provides payment allowances for several CPT® and HCPCS codes for seasonal influenza virus vaccines, when payment is based on 95 percent of the AWP (average wholesale price). The exception is when payment is based on reasonable cost when providers furnish the vaccine in a hospital outpatient department, rural health clinic, or federally qualified health center.

Double check your Medicare Part B payment allowances for these codes, effective for dates of service on or after August 1, 2012:

Watch for Vaccine Amounts Controlled Locally

Payment for some vaccines depends on the local claims processing contractor. For example, local contractors set the payment amounts for Q2034 (Influenza virus vaccine, split virus, for intramuscular use [Agriflu]) and Q2039 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [not otherwise specified]).

"I suspect the carrier pricing is directly connected to the fact that it is a 'not otherwise specified' code," says Kent J. Moore, manager of healthcare delivery and finance systems for the American Academy of Family Practice (AAFP) in Leawood, Kan. "In other words, this is the 'miscellaneous' code for which CMS cannot be expected to have a national price. Each carrier will have to set the price locally."

The Medicare Part B allowance kicks in for some other influenza vaccine codes only after the local claims processing contractor verifies that the vaccine is medically reasonable and necessary for the beneficiary. These include:

• 90654 -- Influenza virus vaccine, split virus, preservative-free, for intradermal use (Fluzone ID®) (Part B allowance $18.981)
• 90660 -- Influenza virus vaccine, live, for intranasal use (FluMist®) (Part B allowance $23.456)
• 90662 -- Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Fluzone High-Dose®) (Part B allowance $30.923).

Explanation: Payment for some codes depends on medical necessity, possibly because of the costs compared to traditional injectable influenza vaccines. For example, code 90662 applies to the "enhanced immunogenicity" influenza vaccine. The condition doesn't apply to all patients, which means the target population is probably limited. That leads to the need for a medical necessity determination.