Pulmonology Coding Alert

Question: How do you get reimbursement for flu or pneumonia shots administered on the same day as the office visit? Does either shot have to be billed with an underlying diagnosis, like COPD?

Anonymous Wis. Subscriber

Answer: Use CPT administration codes 90471-90472(immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid]). You can also bill the office visit (99201-99215), depending on carrier coverage.

Medicares policy on immunizations without an office visit requires G0008 (administration of influenza virus vaccine) and G0009 (administration of pneumococcal vaccine). These vaccines may be reimbursed regardless of the setting in which they are furnished. The administration fee for these vaccines is eligible for payment in addition to payment for any visit service. Generally you don't need an underlying condition for reimbursement on these shots, but you must report code V04.8 for the flu and V03.82 for pneumonia. As always, depending on the insurance company, some patients will have to assume payment responsibility.

According to Medicare, influenza virus vaccine (90657, 90658, 90659, 90724) coverage is provided for influenza virus vaccine once a year in the fall or winter (flu year, beginning May 1 through April 30 of the following year). Medicare does not require for coverage purposes that the vaccine must be ordered by a doctor of medicine or osteopathy.

Therefore, the patient may receive the vaccine upon request without a physician's order and without physician supervision. For example, if a child under three years receives a flu shot, report code 90657 (influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use). For a child older than three years, use code 90658. For a full influenza virus vaccine, regardless of the patient's age, you would use code 90659. Medicare will pay once per lifetime for pneumococcal (pneumonia) vaccine (90669, 90732). Payment is made at 100 percent of the allowable charge for pneumococcal pneumonia vaccine and its administration to a patient if it is ordered by a physician (MD or DO).

This includes revaccination of patients at highest risk of pneumococcal infection. For a pneumonia shot, use code 90669 (pneumococcal conjugate vaccine, polyvalent, for intramuscular use). To indicate that the shots are different and separate services, some carriers may require the use of the -25 modifier on the E/M service to indicate a separate service was performed on the same day.

Editors note: Advice for this question was provided by Susan Callaway-Stradley, CPC, CSS-P, independent coding consultant in N. Augusta, S.C.