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Pulmonology Coding Alert

Are You Coding Influenza Vaccinations Correctly?

Published on Thu Jan 01, 2004

CPT 2004 deletes whole-virus code

Although coding influenza vaccinations may seem straightforward, pulmonology coders could run into reimbursement trouble if they use 90659 in 2004 because CPT deletes the whole-virus influenza code.

When reporting the pulmonologist's influenza vaccination services, coders should choose from 90658, G0008 and 90471, depending on the payer. Here's how:

Bill for Injection and Supply

Typically, the patient's insurer determines the codes you'll use to report flu shots and vaccination supply.

When billing a Medicare carrier for flu vaccinations, report G0008 (Administration of influenza virus vaccine when no physician fee schedule service on the same day). You may report G0008 in addition to the immunization code 90658 (Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use).

If a private carrier covers that patient or if the insurer doesn't follow Medicare guidelines, assign administration code 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]) for the flu injection. Also, you can bill for the vaccine supply, using 90658, because 90471 does not include payment for injected material.

Remember that you can no longer report 90659 (Influenza virus vaccine, whole virus, for intramuscular or jet injection use) to any carrier. CPT deleted the code because companies don't manufacture the whole-virus vaccine anymore.

To medically justify flu vaccination shots, link ICD-9 code V04.81 (Need for prophylactic vaccination and inoculation against certain viral disease; influenza).

Report Flu and Pneumonia Shots Together

What should you do if the nurse gives a patient a flu and pneumonia vaccine injection (G0009, Administration of pneumococcal vaccine when no physician free schedule service on the same day) on the same date of service? If you're reporting to Medicare, assign G0008 (... influenza...) and G0009, says Renee Brown, CPC, Southeastern Lung Care, Conyers, Ga.

You should report the vaccine with code 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use), coding experts say.

For private insurers, you should report add-on code +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) in addition to 90471. And don't worry about attaching modifier -51 (Multiple procedures) - never attach modifiers to add-on codes, because they represent physician services that are additional portions to other primary procedures. Also in this case, use 90732 for the vaccine.

New Vaccine Requires 90473

For some private insurers, you may bill for the new intranasal flu vaccine using a nonintramuscular immunization code. The Food and Drug Administration recently licensed the intranasal flu vaccine FluMist, says

Richard H. Tuck, MD, FAAP, a nationally recognized speaker on coding, compliance and reimbursement. If your pulmonologist plans to offer FluMist, you should report the services using the following codes:

  • administration - 90473, Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)

  • product - 90660, Influenza virus vaccine, live, for intranasal use.

    Note, however, that the FDA approved FluMist for healthy patients between the ages of 5 and 49, which excludes most Medicare patients. And, physicians can't administer FluMist to patients with cancer or AIDS.

    Assign 99211 With Caution

    When you bill for the flu shot administration, don't try to slip in 99211 (Office or other outpatient visit ... established patient ...) as well, because Medicare considers this service bundled into flu shot administration codes, Brown says. Carriers bundle the services because nurses typically don't provide additional evaluation following the shots.

    But you may report the appropriate E/M code if the nurse or pulmonologist provides a medically necessary service above and beyond the flu shot administration, says Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.

    For example, when the patient has dizziness (780.4) following the flu shot, the nurse takes the patient's vital signs, confers with the physician and implements care. In that case, the nurse has provided a separate service for a condition beyond the flu shot administration.

    In another instance, a patient may present for educational review of his asthma medication regime, and the nurse says the patient is due for his annual flu shot. In that case, you could appropriately bill 99211.

    Some coders recommend that you attach 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 when billing private insurers. Before using this modifier, make sure to check with your insurer for its modifier -25 guidelines.

    If your insurer follows Medicare guidelines and the National Correct Coding Initiative, but doesn't accept G0008, the insurer will bundle 90471 into 99211, coding experts say. The Federal Register gives 90471 (flu shot administration) a "T" status, which means carriers will not pay for the shot administration if the physician performs and reports another service on the same day. Therefore, check with your carrier before submitting a claim for both 90471 and 99211.

    Aim for Higher E/M Levels

    If the physician or nurse practitioner treats the patient's dizziness, you may be able to report a higher-level E/M service, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm based in Lansdale, Pa. But make sure the physician provides sufficient documentation of a history, exam and medical decision-making to warrant the E/M, she says.

    Rely on diagnosis codes to prove medical necessity for the E/M service and flu shots. Linking the ICD-9 codes demonstrates the services' medical necessity and increases the likelihood that the insurer will pay for the nurse's or physician's work, Falbo says.

    Use diagnosis code V04.81 (Need for prophylactic vaccination and inoculation; influenza) when reporting either G0008 or 90471. For the E/M service described above, link 780.4 (Dizziness) to 9921x.

     

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