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Pulmonology Coding Alert

Watch for Preservatives, Payer on Flu Shots or Risk Denials

Published on Wed Jan 28, 2009

G codes will ensure that your Medicare claims process smoothly.

Remember the different reporting rules for Medicare and private payers, or denials for your physician's vaccination services could leave you feeling queasy. Check out this primer on separating the coding rules for flu vaccinations.

Check the Box for Preservative Answers

When reporting the flu vaccine supply, choose from either 90656 (Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use) or 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use), confirms Deb Chandler, BA, CPC, ACS-FP, CCP, with FPA in Columbus, Ohio.

You'll use 90656 for vaccines without preservatives, and 90658 when the vaccines contain preservatives, Chandler says.

How to tell: 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] states whether it has thimerosal preservative," she says.

If the packaging does not help, contact the manufacturer and ask if the vaccine contains thimerosal. Then, make sure other coders and physicians know which vaccines contain preservatives and which do not. Most of the single-dose pre-filled syringes are preservative-free, whereas the multi-dose vials are not, points out Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. For help determining the preservative-free status, visit www.cdc.gov/flu/about/qa/vaxsupply.htm#table.

G Codes Good for Medicare Admin

The patient's payer is not an issue when selecting flu vaccine supply codes, but you'll have to know the insurer to select the correct administration code. For Medicare payers, and payers that follow Medicare rules, you'll report G0008 (Administration of influenza virus vaccine) for the administration, says Stacie Krase, billing specialist at Northern Lake Medical in Gurnee, Ill.

Example: A 73-year-old Medicare patient reports to the pulmonologist's office for a scheduled flu shot. The nurse administers the preservative-free immunization. In this instance, report 90656 and G0008.

When you provide the same service to a patient with commercial insurance, you'd report 90656 for the supply and 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the administration -- if the flu vaccine is the only injection of the encounter.

2-Plus Injections Calls for Coding Adjustment

Medicare and private payers also have differing coding conventions for encounters in which your pulmonologist provides a flu vaccine and another vaccine during the same encounter.

The most common multiple-immunization scenario for most pulmonary practices is the flu/pneumonia vaccine combination, Chandler reports. If the pulmonologist provides these vaccines to a patient with private insurance, report the following:

• 90656 or 90658 for intramuscular use of the flu vaccine supply

• 90471 for the flu vaccine administration

• 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 pneumonia vaccine supply

• +90472 (... each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]) for the pneumonia vaccine administration.

But for a Medicare payer, you'd report the same multi-shot scenario thusly:

• 90656 or 90658 for the flu vaccine supply for intramuscular use

• G0008 for the flu vaccine administration

• 90732 for the pneumonia vaccine supply

• G0009 (Administration of pneumococcal vaccine) for the pneumonia vaccine administration.

Note: Medicare also has an administration code for hepatitis B vaccine; use G0010 (Administration of hepatitis B vaccine) for the administration of this vaccine. For private insurers, stick with +90472 for the administration of any subsequent vaccines, reports Sheila Dullum, CPC, coder at Meriter Medical Clinic in Middleton, Wis. For example, if the physician administers three separate immunizations during the same session for a non-Medicare patient, report 90471 and +90472 x 2, Dullum explains.

Watch out: Don't get the above confused with the administration of a combination vaccine such as Td (tetanus-diptheria) or MMR (measles, mumps, rubella), says Pohlig. Remember to report the appropriate vaccine code and 90471 for the administration since the vaccine was administered with one "stick" (i.e., injection).

Sniff Out Intranasal Vaccine Administration

Remember, 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.

Supply: Rather than 90656 or 90658, you'll code intranasal vaccine supply with 90660 (Influenza virus vaccine, live, for intranasal use), regardless of the payer.

Admin: Report intranasal vaccine administration with 90473 (Immunization administration by intranasal or oral route; one vaccine [single or combination vaccine/toxoid]) for private payers; for Medicare stick with G0008.

You should use G0008 "because the definition in the HCPCS manual is simply 'administration of the flu vaccine'; it doesn't give a specific route for this administration," Chandler explains. 

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