Primary Care Coding Alert

2011 brings changes to flu vaccines and counseling codes.

Your vaccine coding in 2011 will be anything but dull, thanks to changes in codes and administration reporting. Two more updates every FP should know involve new Q codes for some Medicare flu vaccines and expanded ages for adolescent vaccine counseling.

Nix 90658 for Medicare Patients in 2011

CMS has created new HCPCS codes and payment allowances to replace 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use). Medicare will no longer pay for 90658 effective Jan. 1, 2011, so choose from the new codes instead, based on the specific product:

• Q2035 -- Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
• Q2036 -- Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
• Q2037 -- Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
• Q2038 -- Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
• Q2039 -- Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified).

Timing: Codes Q2035-Q2039 went into effect Oct. 1, 2010. You have two choices when filing claims for dates of service from Oct. 1, 2010 until Dec. 31, 2010: bill Medicare immediately with 90658, or hold the claim until Jan. 1, 2011 and file with the appropriate Q code. For vaccines administered after Jan. 1, 2011, only report the applicable Q code.

Explanation: Medicare pays for influenza vaccine based on 95 percent of the average wholesale price. "The products normally classifiable to 90658 have widely varying AWPs," says Kent J. Moore, manager of healthcare delivery and financing systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. "If Medicare continued paying for all of them under a single code, they would be overpaying some and underpaying others, relatively."

Result: Medicare assigns different Q codes to each individual product beginning Jan. 1, 2011 to account for variances in manufacturing prices. "This should actually help ensure that physicians are paid fairly for products that might have significant cost differences," Moore adds.

For more information on implementing the new Q codes, see MLN Matters (MM7234) from CMS.

Use 90460, +90461 Through Age 18

You'll be able to use medicine series vaccine administration with counseling codes on older patients and when a nurse provides the counseling, thanks to CPT 2011.

Because counseling for adolescents can involve as much time as counseling on vaccines for younger children, the American Academy of Pediatrics recommended that the age limitation on the vaccine administration with counseling codes be raised. New codes (90460, Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component and +90461, Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component [List separately in addition to code for primary procedure]) extend vaccine administration with counseling to patients through 18 years of age.

Take Advantage of RN/LPN Counseling -- and Still Get Paid

Busy practices will be thrilled at being able to use their registered nurses (RN) or licensed practicing nurses (LPN) to capture the higher relative value units some private payers associate with the vaccine administration with counseling codes. The new vaccine administration with counseling code descriptor expands who can provide the vaccine counseling described in the deleted immunization administration with vaccine counseling codes (90465-90468). CPT 2010 vaccine administration with counseling codes 90465-90468 limited the counselor role to a physician and, subject to state scope of practice laws, nurse practitioner (NP) or physician assistant (PA).

The new vaccine administration with counseling code extend the counseling opportunity to any "qualified health care professional" practicing within his/her state described scope of practice. An RN, LPN, or medical technician could provide the counseling and the practice could still use the vaccine administration with counseling code.

Final note: Remember the new administration codes, 90460 and 90461, are per vaccine/toxoid component. That means if your physician provides counseling and administering for a combination vaccine such as MMR (90707, Measles, mumps, and rubella virus vaccine [MMR], live, for subcutaneous use), you'll report 90460 for the first component and 90461 for each additional component. In the MMR example, you would report 90460 once (for the measles component) and 90461 twice (for the mumps and rubella components). Prior to 2011, you would report only a single vaccine administration code for a combination vaccine, regardless of the number of components in the vaccine.