Pulmonology Coding Alert

Key: Focus on product and administration for complete reporting.

When your pulmonologist provides pneumovax vaccines, don't miss out on reporting administration codes as this could lead to partial payments for the services rendered. Avoid leaving money on the table with these vaccine billing tips.

Get Specific About These Items

If your pulmonologist administers a pneumovax vaccine, ensure that she provides adequate documentation to support the medical necessity of providing the vaccine. Some instances of medical necessity will include age over 65 years with respiratory issues like asthma or COPD; patients with other medical conditions like congestive heart failure, cirrhosis, diabetes mellitus; and patients who are immunosuppressed (due to chemotherapy, HIV, after organ transplantation, or currently on immunosuppressive drugs).

The documentation provided should also include details such as the type (manufacturer and lot #) of vaccine that is administered and the route of administration employed by your pulmonologist. The purpose of administration and patient response should also be included in the documentation.

When your pulmonologist administers a pneumococcal conjugate vaccine, you report the vaccine with one of the following codes:

• 90669 (Pneumococcal conjugate vaccine, 7 valent, for intramuscular use)
• 90670 (Pneumococcal conjugate vaccine, 13 valent, for intramuscular use)
• 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use)

"The CDC (Centers for Disease Control) recommends pneumococcal conjugate vaccine (90669, 90670) for all children less than 59 months old," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia. "In addition, children more than 24 months old who are at high risk of pneumococcal disease and adults with risk factors may receive the pneumococcal polysaccaride vaccine (90732)."

Example: Your pulmonologist assesses a 66-year-old patient with chronic airway obstruction for pneumonia. As the patient's age and existing medical problem puts the patient in the high risk category for pneumonia, he decides to administer pneumococcal polysaccharide vaccine to the patient as a preventive measure. The documentation should provide details of the chronic airway obstruction (496, Chronic airway obstruction, not elsewhere classified) that will inform the payer about the medical necessity of the vaccine administered.

Capture Appropriate Administration Codes Depending on Payer

When your pulmonologist provides PCV to a Medicare patient, you need to report the administration using the HCPCS code G0009 (Administration of pneumococcal vaccine).

For other insurance payers, you can use the CPT® code 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]). If other vaccines are also provided during the same session, you cannot report the administrations with additional units of 90471.

Instead, you will have to use the add-on code +90472 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]).

"Typically, PCV is administered once in a lifetime, but Medicare will pay claims for beneficiaries who are at high risk and have not received a pneumococcal vaccine within the last five years or are revaccinated because they are unsure of their vaccination status," adds Pohlig.

Reminder: Be sure to link V03.82 (Need for prophylactic vaccination and inoculation against bacterial diseases; Streptococcus pneumoniae [pneumococcus]) to 90732 and 90471 (or G0009) to prove medical necessity for the service.

Example: Your physician administers both pneumonia and flu vaccinations to a patient with asthma. You report 90471 and +90472 for the administrations. You also list supply codes 90732 and 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) (or the most appropriate flu vaccine code recognized by the payer). Don't forget to link V06.6 (Need for prophylactic vaccination and inoculation against streptococcus pneumoniae [pneumococcus] and influenza) to both 90732 and 90658.

Know When to Report an E/M Code Separately

When the patient presents to your pulmonologist for another problem and during the same visit your pulmonologist administers PCV, then you can report the appropriate E/M code such as 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient...) for new patients or 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient...) for established patients. Some insurance carriers might also want you to report a modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code that you are reporting.

If your pulmonologist were to undertake any other procedures in addition to the administration of the vaccine during the same session, you do not have to append the modifier 51 (Multiple procedures) to 90732. This is because vaccine codes are modifier 51 exempt as you usually report the modifier only for procedural services.

Example: An asthmatic patient previously seen by your pulmonologist presents with complaints of wheezing not being alleviated by the use of the metered dose inhaler previously prescribed to the patient. Your pulmonologist undertakes a comprehensive evaluation of the patient and assesses why the medication is not working. He realizes that the patient is not using the metered dose inhaler properly and again provides instructions for the correct use of the device. During the session, your pulmonologist based on the patient's present condition arrives at the decision that the patient has a high risk of developing pneumonia in the future and administers pneumococcal conjugate vaccine.

You report the E/M visit with 99214-25, the instructions to use the aerosol generator with 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) and the PCV administration with 90732.