Pulmonology Coding Alert

Hint: Follow totally different reporting system for Medicare patients.

When your pulmonologist administers vaccine(s) to a patient, you’ll focus on the patient’s age, counseling (if performed), route of administration and the number of vaccines provided.

Watch For Counseling in Young Patients

When your pulmonologist performs vaccine administration to a patient younger than 18 years and provides counseling about the vaccine to either the patient or to the patient’s parents, you have to report the administration with 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered). As the descriptor clearly states, the same code is used regardless of whether the vaccine was given intramuscularly, orally, or intranasally.

If more than one single-component vaccine is administered along with counseling to a patient younger than 18 years, each vaccine administered should be reported with 90460, according to the AMA CPT® 2012 Errata (http://www.ama-assn.org//resources/doc/cpt/cpt-changes-corrections.pdf),.

In other words: “Report two units of 90460 for pneumococcal and influenza vaccine given on the same day,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia..

However, if your physician is administering one combination vaccine that covers more than one condition, you should count the individual components of the vaccine to accurately report it. For example, if the vaccine administered is providing coverage for four conditions such as Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), you would report one unit of 90460 and three units of +90461 (…each additional vaccine or toxoid component administered [List separately in addition to code for primary procedure]) even though your clinician only administered one vaccine but counseled for all four components of the vaccine.

Deploy These Four Codes For Older Patients

When a vaccine is administered to a patient older than 18 years or if administered to a child younger than 18 but no counseling is provided, you report the administration using these four codes depending on the route of administration:

• 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid])
• +90472 (…each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure])
• 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid])
• +90474 (…each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure])

So, if your clinician administers two vaccines intramuscularly, you report the first vaccine administration with 90471 and the second with +90472. If the two vaccines were administered orally or through the nose, you report the first vaccine with 90473 and the second with +90474.

Caveat: “Different from 90460-90461, 90471 and 90473 have reporting limitations,” reminds Pohlig. “You cannot report more than one unit of 90471 or 90473, and you cannot report these codes together.” 90473 is bundled into 90471 as per Correct Coding Initiative (CCI) edits with the modifier indicator ‘0,’ which means that these two codes cannot be reported together under any circumstances. So, if your clinician is providing one vaccine intramuscularly and the other through the nose as a spray, you’ll have to report the injected vaccine with 90471 and the intranasally administered vaccine with the add-on code +90474.

Example: Your pulmonologist administers pneumovax-23 and trivalent Flulaval to a 50-year-old male patient. Since your pulmonologist administered two vaccines intramuscularly, you report the administration of the first vaccine with 90471 and the second one with +90472. Don’t forget to report the supply of the vaccine with 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use) for the pneumovax and 90658 (Influenza virus vaccine, trivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use) for the Flulaval.

Suppose, instead of Flulaval, if your clinician administered FluMist spray, you report the intramuscular injection of the pneumovax with 90471 and the administration of the FluMist with +90474. Alternatively, you can also report 90473 for the FluMist and report the pneumovax with the add-on code +90472. Don’t forget to report 90660 (Influenza virus vaccine, trivalent, live, for intranasal use) for the supply of the FluMist.

Substitute With Alternate G Codes For Administration to Medicare Patients

When your pulmonologist administers vaccines to Medicare patients, you’ll have to use other codes than 90471-90474 to report the administration. Unlike these codes, the administration of vaccines to Medicare patients is reported specifically depending on the vaccine that is administered.

So, depending on the vaccine administered, you’ll have to report the following G codes when a Medicare patient receives the vaccine:

• G0008 (Administration of influenza virus vaccine)
• G0009 (Administration of pneumococcal vaccine)
• G0010 (Administration of hepatitis B vaccine)

Example: As in the example described earlier, if your pulmonologist was administering Flulaval and pneumovax 23 to a Medicare patient, you’ll report G0008 for administration of Flulaval and report G0009 for the pneumovax administration. You also have to report other codes for the supply of the influenza vaccine. You’ll have to report Q2036 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use [Flulaval]) for the supply of the Flulaval.

Know When to Report Separate E/M Code With Vaccine Administration Codes

When your pulmonologist administers a vaccine to a patient, if he records a brief history, checks the patient’s vitals and rules out any contraindications to the administration of the vaccine, you only have to report the vaccine administration codes and not report any evaluation and management (E/M) codes for the visit.

Any E/M office or inpatient codes are bundled into the vaccine administration codes 90460, 90471 and 90473 with the modifier indicator ‘1,’ which means you can unbundle the codes if a modifier is appended to the E/M code, the Correct Coding Initiative (CCI) edits indicate.

So, you can report an E/M service with a vaccine administration code if and only if the E/M service was separate and significant from the vaccine administration. If a significant and separately identifiable service was performed, you report the appropriate E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to it to show that the E/M service was distinct from the vaccine administration performed.

Example: An asthmatic patient who is under the care of your pulmonologist reports for his influenza vaccination. During the visit, the patient complains that his wheezing symptoms have increased and the occurrence of symptoms at night has increased the incidence of his awakening in the night.

Your pulmonologist reviews the patient’s history, checks his medication history and performs an expanded problem focused examination of the patient and makes adjustments to the use of the metered dose inhaler the patient is using.

The patient also receives his flu vaccine as scheduled. So, in this case scenario, since your pulmonologist also reviewed the patient’s asthmatic condition, you can report 99213 with the modifier 25 along with the flu vaccine administration code, 90471.