Pulmonology Coding Alert

Use this guide to determine the correct vaccine and administration codes

With different rules for Medicare and private carriers on reporting flu shot services your pulmonologist or nurse provides, you may find yourself wondering whether you're reporting the correct codes. If you remember these four basic steps, you'll be able to report flu shot administration with ease.

1. Use the patient age, vaccine type and form of administration to determine the correct code for the vaccine. You need to take into account three criteria when figuring out which flu shot code to report.

• For all patients 3 years old and above, select either 90656 (Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use) or 90658 (Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use).

For patients between 6 and 35 months, choose either 90655 (Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use) or 90657 (Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use).

• Choose between preservative-free and regular vaccine. The only difference between the two vaccine codes in each age category is that one denotes a preservative-free vaccination, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, N.J. Codes 90656 and 90655 represent preservative-free vaccines, and 90658 and 90657 represent regular vaccines.

• Make sure the vaccine your physician administered wasn't intranasal. For all intranasal vaccines, you should report 90660 (Influenza virus vaccine, live, for intranasal use).

2. Choose an administration code based on other services your pulmonologist provides. Reporting a flu shot encounter is a two-code process, says Denae M. Merrill, CPC, coder with Covenant MSO in Saginaw, Mich. You need to choose one of the following administration codes to complement the vaccine code you're reporting:

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

• When the patient receives a flu shot in addition to another primary vaccine, bill private payers using 90471 with +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]).

• Use G0008 (Administration of influenza virus vaccine when no physician fee schedule service on the same day) to bill Medicare for flu shot administration.  Note that the National Correct Coding Initiative (NCCI) bundling edits specifically state that you cannot report G0008 with an E/M service code (99201-99357).

• When the patient receives an intranasal vaccine, bill private payers using 90473 (Immunization administration by intranasal or oral route; one vaccination [single or combination vaccine/toxoid]) or +90474 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) depending on the number of vaccines your physician administers, Merrill says.

3. Remember the diagnosis code. You should link V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases; influenza) to both the vaccine code and the administration code to show medical necessity for both services, Cobuzzi says. Some insurers require an additional diagnosis code to identify patients who are at increased risk for the flu (eg., chronic obstructive pulmonary disease, COPD).

4. Report any separate E/M service with modifier 25. Example: A 68-year-old Medicare patient comes in for a flu shot and evaluation of asthma symptoms. The nurse administers an intramuscular, preservative-free vaccine, and the doctor renders a level-three established patient E/M service to evaluate and treat the patient's asthma condition. Report 90656 linked to V04.81 for the flu shot, and 99213 linked to the appropriate diagnosis code, for example, 493.11 (Intrinsic asthma, with status asthmaticus), for the E/M visit.

Then append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99213 to ensure payment of both services. You do not need to report an administration code because you may only report G0008 to Medicare when there is no other billable service rendered during the encounter.