Pulmonology Coding Alert

CMS changed the rules for flu-shot diagnoses -- get the details below

Flu season is under way, so you probably have patients lined up at your door for their shots. Ease your flu-shot coding worries with five quick tips that can put you on the fast track to reimbursement.


Tip 1: Select the Code for the Vaccines

Reporting a flu shot is a two-code process, and you should first choose the correct vaccine code, and then the appropriate administration code.

To determine which vaccine code applies to your patient, you should direct your attention to codes 90656 (Influenza virus vaccine, split virus, preservative-free, when administered to 3 years of age and older, for intramuscular use) and 90658 (Influenza virus vaccine, split virus, when administered to 3 years of age and older, for intramuscular use).

What's the difference? You'll probably report 90658 more frequently than 90656, because 90656 refers to a preservative-free vaccination, which physicians use less frequently. That's the only difference between the two codes.

You should check the documentation or the vaccine's packaging to determine which type the staff administered, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Double-check the administration method: Because more and more physicians use intransasal flu vaccinations each year, you should confirm that staff injected the patient before you report one of the above codes. If the physician performed the vaccination intranasally, on or after Oct. 1, 2006, you should instead report 90660 (Influenza virus vaccine, live, for intranasal use).

Tip 2: Pin Down the Administration Code

Now that you've got your vaccine code in check, you should select the correct code to reflect the practice staff's work administering the shot.

If the flu shot is the primary vaccine that your physician orders, bill private carriers with 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]).

If staff administers the flu shot in addition to another separately injected vaccine for a private insurance patient, you should also report +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) to reflect the second immunization.

Medicare wants G codes: If you bill Medicare for the flu shot administration, report G0008 (Administration of influenza virus vaccine). If the pulmonologist's staff administers an intranasal vaccine, you should bill private payers with 90473 (Immunization administration by intranasal or oral route; one vaccination [single or combination vaccine/toxoid]) or +90474 (... each additional vaccine). If you treat a Medicare patient with the intranasal vaccine, you should avoid 90473-90474 and instead stick with G0008.


Tip 3: Know Your Diagnosis Code

Medicare and most private insurers instruct physicians to link the flu vaccine codes to V04.81 (Need for prophylactic vaccination against certain viral diseases; other viral diseases; influenza). You should use this diagnosis for both the vaccine code and the administration code to show medical necessity for both services. Some private payers cover the flu shot for those who are at increased risk (such as asthmatics). In addition to V04.81, the payer also requires the ICD-9 for the co-morbid condition (for instance, 493.90, Asthma, unspecified) on the claim form.


Tip 4: Update Rules for PPV and Flu Shots

Pulmonology practices have often expressed confusion about which codes to report when they administer flu and PPV vaccines on the same date, but a recent Medicare MLN Matters article with an implementation date of Oct. 2, 2006, clears it up.

According to the article, you should report V06.6 (Need for prophylactic vaccination and inoculation against streptococcus pneumoniae [pneumococcus] and influenza) "on claims that contain influenza virus and/or PPV vaccines and their administration when the purpose of the visit was to receive both vaccines."

The breakdown: Therefore, if you're billing private payers for a flu vaccine that includes preservatives, along with a PPV vaccine, you should report 90658 for the flu shot and 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to 2 years of age or older, for subcutaneous or intramuscular use) for the PPV administration, says Lisa Barnes, CPC, coder at Fayetteville Diagnostic Clinic in Fayetteville, Ark.

In addition, you'll report 90471 for the first vaccine and 90472 for the PPV vaccine, Barnes says. Link all of these codes to V06.6.

Watch out: If you're billing Medicare, you should instead report 90658, 90732, G0008 and G0009 (Administration of pneumococcal vaccine), all linked to V06.6, Barnes says.


Tip 5: Bill Separate E/M if Well-Documented
You can report a separately identifiable E/M service with your flu-shot codes as long as your physician fully documents the E/M details and the medical necessity of the visit. You should 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 the E/M code.

If you are billing Medicare, you cannot bill the G code for the administration in addition to a nurse visit (99211). However, a separately identifiable physician service (such as 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) is permitted on the same day as the flu shot.

Keep in mind that the OIG is carefully monitoring claims that physicians report for E/M visits with modifier 25 appended. In fact, the OIG released a report titled "Modifier 25" last year that specifically noted problems with E/M claims when reported with flu shots.

The report stated that 27 percent of modifier 25 claims had documentation of the procedure but not the separate E/M. It noted, "Documentation for one of the records reviewed indicated that a Medicare beneficiary presented for a flu shot. The provider submitted a claim for the flu shot and an E/M service, the latter using modifier 25 ... The provider furnished documentation that a flu shot was provided but no documentation to support the claim for a separate E/M service."

For more information on providing flu shots to Medicare patients, visit www.cms.hhs.gov/AdultImmunizations/Downloads/20062007101006FINALFluGuide.pdf or www.cms.hhs.gov/MLNProducts/downloads/qr_immun_bill.pdf.