Answer: The administration codes for vaccines billed to Medicare and private insurance carriers are not the same. Medicare only accepts G codes, while private insurance accepts standard administration codes.
Follow the guidelines below for proper billing:
Influenza Vaccines
Medicare: The administration of the influenza vaccine is G0008 (Administration of influenza virus vaccine when no physician fee schedule service on the same day). CPT codes are 90657-90659 (Influenza virus vaccine, split virus, 6-35 months dosage, for intra-muscular or jet injection use; 3 years and above ; whole virus ), as appropriate. The proper diagnosis code for the administration is V04.8 (Influenza). Medicare will pay for an office visit (99201-99215) in addition to the administration if the immunization was not the only issue addressed.
Non-Medicare: Use 90657-90659 for the vaccine. The administration codes are 90471 (Immunization administration ) or +90472 ( each additional vaccine). However, 90471 or 90472 may not be billed when reporting an office visit on the same day because the administration is bundled into the visit payment. Like Medicare, the diagnosis code for administration is V04.8.
Note: Typically, flu vaccines are provided to patients who are at risk for contracting the virus (i.e., the young, elderly and the immuno-compromised). The diagnosis code that identifies that risk should be reported with V04.8. For example, in an asthma patient the diagnosis codes would be 493.00 (Asthma) and V04.8.
PPV Vaccines
Medicare: Report 90732 (Pneumococcal polysaccharide vaccine ) for the vaccine; G0009 (Administration of pneumococcal vaccine ) for the administration; and V03.82 (Streptococcus pneumoniae [pneumococcus]) for the diagnosis.
Non-Medicare: Report 90732 with 90471-90472. Codes 90471-90472 may not be paid separately when you report an office visit on the same day. As with the influenza vaccine, this immunization is bundled. The diagnosis code is V03.82.
Report coexisting conditions as the primary diagnosis. For example, if a patient has asthma, the primary diagnosis is 493.00, and the secondary is V03.82.
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