Pulmonology Coding Alert

Question: How do I get paid for flu or pneumonia shots administered on the same day as an office visit? Does either have to be billed with an underlying diagnosis?

Wisconsin Subscriber

Answer: All services provided should be reported. Code the appropriate E/M level based on the documentation and the diagnosis for which the patient was evaluated (i.e., bronchitis). A modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to the E/M code to show it is a separate, identifiable service from the immunization.

Bill the immunizations as follows:

Flu vaccine Code 90657-90659 for the actual vaccine and for the administration; 90471 for one vaccine (single or combination vaccine); and 90472 for each additional one (single or combination).

Pneumonia vaccine Code 90732 for the actual vaccine and the administration; 90471 for one vaccine and 90472 for each additional.

Medicare requires that the administration codes be billed with G0008 for the administration of the flu vaccine and G0009 for the administration of the pneumococcal. These replace the administration codes 90471 and 90472 that are reported as above with all other payers. Medicare allows coverage for two flu vaccines per rolling calendar year, and one pneumonia vaccine in a lifetime unless the patient is considered to be in the highest risk category for contracting pneumonia, in which case the vaccine may be provided once every five years.

Check your local medical review policy for a list of the highest risk category conditions for which it would be reimbursed every five years. Medicare does not require, for coverage purposes, that the vaccine be ordered by a doctor of medicine or osteopathy. Payment is made at 100 percent of the reasonable charge for the vaccine.

Note: Although Medicare, as well as some other payers, will not pay the administration fee separately, it is important that the service be reported for tracking purposes. The administration fee will be rolled into the payment for the E/M code for Medicare. Some private payers will pay for the E/M, administration code and vaccine while others may also roll the administration fee into the E/M. Check carrier guidance to determine payment policies. Report V04.8 for the flu and V03.82 for pneumonia vaccines and the appropriate diagnosis for which the evaluation was performed on the patient for the E/M charge.