Pulmonology Coding Alert

What's More: Intramuscular and intranasal vaccines each get separate code sets.

Influenza season persists, and billing for flu vaccination services could leave you high and dry on your efforts if you failed to spot the right coding rule to apply to your practice. Ramp up your profits with tips on influenza vaccine protocols, given the following scenario:

A 73-year-old Medicare patient reports to the pulmonologist for a scheduled flu shot. The pulmonologist provides the preservative-free immunization.

Code it: You should report the service using one CPT and one HCPCS code: 90656 (Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use) and G0008 (Administration of influenza virus vaccine).

Find out what protocols are relevant to the given solution with these 3 tips.

1. Look Into The Type of Vaccine Supply Used

The key rule here is that should report two codes to bill for influenza vaccination services: the appropriate CPT code for the flu vaccine given and the appropriate CPT code for vaccine administration, according to Cindy Hughes, CPC, an American Academy of Family Physicians (AAFP) coding specialist.

When reporting for seasonal vaccine products, you would choose from the following codes:

• 90655 -- Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use;
• 90656;
• 90657 -- Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use;
• 90658 -- Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use;
• 90660 -- Influenza virus vaccine, live, for intranasal use.

Update: Effective Jan. 1, Medicare replaced 90658 with the following codes for split virus vaccines, 3 yrs old, intramuscular:

• Q2035 -- Afluria
• Q2036 -- Flulaval
• Q2037 -- Fluvirin
• Q2038 -- Fluzone
• Q2039 -- not otherwise specified.

Extra: A new high dose influenza vaccine has been made available during 2010/2011 season: 90662 (Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use). Use this code when billing for Fluzone High-Dose, a new flu vaccine, approved in December 2009 for use in people ages 65 and older.

Since the patient received a preservative-free, non-high dose immunization in the scenario given, the appropriate code would be 90656.

Tip: To be able to tell if the vaccine has a preservative, you should check the packaging on the vaccine, recommends Jan Allen, claims and accounts receivable manager for a four-physician practice in Santa Paula, Calif. The insert in the package would almost always state whether the vaccine is preservative-free or not.

2. Administering a Medicare Patient? Go For G0008

For administration of vaccines, you would report one of these codes:

• G0008 -- Administration of influenza virus vaccine;
• 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).

Brief: CPT 2011 has deleted the following CPTs from the list of vaccine administration codes:

• 90465 -- Immunization administration, younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family: first injection (single or combination vaccine/toxoid), per day;
• 90466 -- ... each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure);
• 90467 -- Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/ family: first administration (single or combination vaccine/toxoid), per day; and
• 90468 -- ... each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure).

Don't forget that the payer plays an important role when choosing the appropriate vaccine administration code. For Medicare payers, and payers that follow Medicare rules, you would report G0008 -- just like what the scenario above indicates.

Let's say the flu vaccine is the only injection of the encounter, and the physician provided the same service to a patient with commercial insurance, then you should bill 90471.

Also, it is possible for your pulmonologist to provide a flu immunization to a patient intranasally. When this occurs, you need to be ready to adjust your coding and report:

• 90660 for supply, regardless of payer
• 90473 for administration on private payers; G0008 for administration on Medicare.

Caveat: Although H1N1 is a component of the seasonal vaccines, this does not require separate coding of the H1N1 component, according to the article Organize To Immunize -- Flu Season Is Coming on the AAFP website, which appeared on Aug. 26, 2010. The WHO has declared the H1N1 pandemic over and you should report only the seasonal flu vaccine code and the associated administration code for the 2010-2011 seasonal flu vaccines, the article adds.

You shouldn't report the specific codes developed in 2009 for H1N1 only (i.e., 90470, H1N1 immunization administration [intramuscular, intranasal] including counseling when performed; and 90663, Influenza virus vaccine, pandemic formulation, H1N1), or the new codes for reporting pandemic influenza vaccines (90664-90668).

3. Prepare To Report V04.81 Most of the Time

For majority of your flu shot claims, V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza) is the only diagnosis code you'll need. However, if the patient is at high risk for developing the flu due to a chronic condition (e.g., asthma, 493.90, or COPD, 496), you should list the corresponding condition as a secondary diagnosis, notes Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

However, you might consider another diagnosis code if a flu vaccine and a pneumonia vaccine are given at the same encounter. In this case, you would link V06.6 (Need for prophylactic vaccination and inoculation against combinations of diseases; streptoccocus pneumonaie [pneumococcus] and influenza) to the CPT codes.

From the scenario given, let's say the internist provides a preservative-free flu vaccine injection and a pneumonia vaccine, to the same Medicare patient during the same encounter. On the claim, you'd report:

• 90656 and G0008 for the flu vaccine supply and administration
• 90732 and G0009 for the pneumonia vaccine supply and administration
• V06.6 appended to 90656, G0008, 90732, and G0009.