Know Carrier Guidelines When Coding H1N1

If you’re confused about carrier rules for coding H1N1 vaccines, you’re not alone. Choosing H1N1 codes  in regard to Medicare and private insurance guidelines, and when to use a modifier can leave you dumbfounded. To answer your H1N1 questions, here’s the low-down on Medicare policies vs. private insurer policies.

Four new codes plus one revised code were recently published and are available for use by providers and public/private health insurers in submitting/reimbursing claims for H1N1-related services.

Medicare HCPCS Level II Codes

Two new HCPCS Level II H1N1 vaccine and administration codes were created by the Centers for Medicare & Medicaid Services (CMS), effective Sept. 1.

G9141 Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family) is for the administration; G9142 Influenza A (H1N1) vaccine, any route of administration is for the product.

When billing the H1N1 vaccine, apply the same rules as you would for the seasonal influenza vaccine; however, there is one exception. Because the H1N1 vaccine is available at no cost to providers, Medicare does not pay providers for the vaccine. It is not necessary to list HCPCS Level II code G9142 on the Medicare claim when vaccine administration code G9141 is reported. For more information on H1N1 virus vaccine and administration reporting read Medicare’s MLN Matters.

Non-Medicare CPT® Codes

Effective Sept. 28, use newly revised CPT® code 90663 Influenza virus vaccine, pandemic formulation, H1N1 to report the H1N1 vaccine product. For reporting the vaccine administration, use new CPT® code 90470 H1N1 immunization administration (intramuscular, intranasal), including counseling when performed.

Because the federal government is providing the H1N1 vaccine for free and there are two sets of codes available, you should check with individual payer guidelines on how to report H1N1 vaccine and administration. For example, payers may instruct you to report the H1N1 vaccine in one of the following ways:

  • Report CPT® code 90663 or HCPCS Level II code G9142 with a zero dollar ($.00) charge.
  • Report CPT® code 90663 or HCPCS Level II code G9142 charged as $.00 and link it to Modifier SL State supplied vaccine.
  • Report CPT® code 90663 or HCPCS Level II code G9142 with a charge of $.01 (some systems cannot process claims with a zero dollar charge).
  • Report the administration only (90470 or G9141) and not the vaccine.

Note: The Medicare beneficiary may not be charged any amount for the vaccine and he/she must be informed about the $.01 charge that may appear on the Medicare Summary Notice (MSN).

What’s the Diagnosis Doctor?

Reporting ICD-9-CM diagnosis code V04.81 Influenza for the purpose of administering the vaccine is appropriate for private and public insurance.


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2 Responses to “Know Carrier Guidelines When Coding H1N1”

  1. Tiffany says:

    I was told that ICD9 488.1 is to be used instead of V04.81. Does this apply to all insurances or do we still use V04.81 for Medicare in conjunctino with G9141 and G9142?

  2. renee says:

    CMS says, for Medicare, report V04.81 with vaccine admin code G9141. What your payer says, I don’t know. Best to ask them.

    My understanding is that ICD-9 488.1 is for reporting suspected or diagnosed H1N1 with an E/M code.

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