ED Coding and Reimbursement Alert

Swine flu's earlier-than-expected sweep into some states has coders everywhere wondering how -- and what -- they should code when the ED is involved in administering a vaccine to combat the condition.

The kicker: It isn't that there is no way to code for the H1N1 administration; there are new CPT and new Medicare G codes specifically tailored for reporting the service, confirms Michael Granovsky, MD, CPC, FACEP, president of Medical Reimbursement Systems Inc. (MRSI), an ED billing company in Woburn, Mass. These codes, however, represent facility resources in the ED setting.

Of course, that won't stop ED patient presentations for swine flu vaccination. Follow this FAQ for the best advice on ethically coding H1N1 administration.

What Can the ED Physician Report on the Claim?

If you code in the ED setting, administration "is a facility service, so [it is] not billable by the doctor," explains Granovsky (for example, if your hospital is running an outpatient vaccine clinic but utilizing ED staff).

Silver lining: A pre-vaccination E/M service is possible for certain H1N1 vaccine patients. "If the patient has a specific medical complaint, the ED physician will likely provide an EMTALA-mandated screening exam, and the ultimate E/M code would be based on the history, physical exam, and medical decision making documented in the record," Granovsky explains.

Example: A 48-year-old female reports to the ED feeling weak and tired. After examination and a rapid screen, the physician determines the patient does not have H1N1 or any other viral illness, but rather is anemic due to heavy vaginal bleeding associated with fibroids. The patient requests an H1N1 vaccination, which the ED nurse provides.

In this instance, you might be able to report an ED E/M for the physician's prevaccination service (99281-99285). Payers will want to see a secondary diagnosis of V04.81 (Need for prophylactic vaccination and inoculation against certain diseases; influenza) for H1N1 administration claims the facility bills to support medical necessity.

If the patient has a true active viral "flu" infection, you'll also choose a primary diagnosis from the 487.x- 488.x sets, depending on the patient's condition. (For more information on coding unconfirmed H1N1 cases, see "Diagnostic Statement Is the Key to Unlocking Flu Dx" on page 101.)

In the ED, an E/M service will apply only if the patient requires a specific medical evaluation; however, in the urgent care setting, where the facility and professional charges are often reported together, you can use the new administration codes. Reporting administration in the urgent care setting requires learning some new codes.

CPT option: The AMA fast-tracked a CPT code for vaccine administration specifically for H1N1, explains Richard Tuck, MD, FAAP, at PrimeCare of Southeastern Ohio in Zanesville. Code 90470 (H1N1 immunization administration [intramuscular] [intranasal] including counseling when performed]) is effective immediately.

Medicare option: Medicare will want you to use new G code G9141 (Influenza A [H1N1] immunization administration [includes the physician counseling the patient/family]), confirms Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Check out Medicare's latest MLN Matters article on H1N1 for more information at: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0920.pdf.

When you are billing for administration in the urgent care setting, Medicare wants to see G9141 in all cases; private payers, however, are a mixed bag, Pohlig points out. Some plans are accepting either G9141 or 90470.

There are reports that some other carriers will accept only 90470 for administration.

Bright idea: "Some practices are making it easy and intend to report G9141 across the spectrum of payers" that allow for either admin code, Pohlig says. Doing this could streamline your practice's H1N1 coding. Many payers are still getting used to the idea of a new flu admin code, so you should check with your local payers before coding administration, then decide the most efficient way to code.

You can, but you won't get paid for it. Medicare also created G9142 (Influenza A [H1N1] vaccine, any route of administration) to represent the vaccine supply.

Since the vaccine is currently being given away by the feds, however, you should not charge for the vaccine supply. So if you code G9142 for tracking purposes, be sure to enter the charge as $0. If G9142 appears on the claim this way, only the claim line will be denied. If you are using CPT codes and decide to code for the vaccine, the AMA also instructs you to report 90663 (Influenza virus vaccine, pandemic formulation) at $0.