Internal Medicine Coding Alert

Published on Mon Feb 01, 2010 PDF

Be at the ready with these codes if H1N1 resurfaces.

You'll be hard-pressed to find recently approved vaccine codes in CPT 2010 -- that's because most of the following codes won't be published, or updated, in the manual until next year. In the meantime, use this guide to keep your vaccine coding options open.

Update: The American Medical Association (AMA) released an update on vaccine codes on Feb. 26, 2010 at www.ama-assn.org/ama1/pub/upload/mm/362/vaccinecodes.pdf.

Remember: Medicare will cover only some of the codes listed below. "In general, Medicare will only pay for flu and pneumonia (pneumococcal) vaccines," notes Penny Osmon, CHC, CPC, CPC-I, PCS, coding and reimbursement educator at the Wisconsin Medical Society in Madison. "[It also] will pay for hepatitis B for those who are defined as high-risk."

AMA removed the Food and Drug Administration (FDA) approval pending indicator from code 90670 (Pneumococcal conjugate vaccine, 13 valent, for intramuscular use) after notification on Feb. 23, 2010 that this product has achieved FDA approval status.

Coverage: Medicare covers this code once per lifetime. This revision is effective Feb. 23, 2010, although it will not appear in the printed copy of CPT until the publication of the CPT 2011 codebook.

"The effective date is the go-live date for coverage," explains Osmon, so you may report this code for the 13- valent pneumococcal vaccine for dates of service starting from Feb. 23, 2010.

Note: In certain situations, Medicare allows revaccinations for beneficiaries at highest risk for pneumococcal disease and those most likely to have rapid declines in antibody levels, according to the Medicare Preventative Service (MPS) Guidelines, page 166 (www.cms.hhs.gov/mlnproducts/downloads/psguid.pdf). If a beneficiary is uncertain about his pneumococcal vaccination status, Medicare will pay for the pneumococcal revaccination.

The H1N1 influenza pandemic generated a revised product code and a new administration code. Report revised code 90663 (Influenza virus vaccine,pandemic formulation, H1N1) for the H1N1 influenza virus vaccine.

AMA presents a new administration code, 90470(H1N1 immunization administration [intramuscular, intranasal], including counseling when performed), for the administration by any route -- however, don't reportthis code to Medicare.

Important: Medicare pays for the administration of the H1N1 virus vaccine with CPT code 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injection]); 1 vaccine [single or combination vaccine/toxoid]), notes Jean Acevedo, LHRM, CPC, CHC, CENTC, president of Acevedo Consulting in Delray Beach, FL. Medicare does not pay for H1N1 vaccine administration including counseling as presented by 90470.

Coverage: Medicare covers 90663 and 90471, based on necessity, once per flu season.

AMA published these updated H1N1 codes on Sept.28, 2009 for immediate use. The release also included instructions from the National Drug Code (NDC) directory codes for tracking of the specific product administered: 90472 (Sub-Q/IM) and 90474 (Oral/Intranasal) for non-pediatric patients. (See AMA fact sheet http://www.ama-assn.org/ama1/pub/upload/mm/362/ama-fact-sheet-h1n1-reporting.pdf). These revisions will appear in the printed copy of the CPT 2011 codebook.

AMA also removed the FDA approval pending indicator from code 90662 (Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use) following notification that this product achieved FDA approval on Dec. 23, 2009.

This revision is effective Dec. 23, although it will not appear in the printed copy of CPT until CPT 2011.

Coverage: Currently, everyone is waiting official documentation to see if Medicare and/or other payers will cover this code. Check with individual payers to determine coverage.

If the code is covered, you will likely need to document medical necessity for selecting 90662, says Osmon. Look for CMS to issue guidance on coverage and billing for 90662 as the new flu season approaches.

The following "pandemic" formulations may not be covered by Medicare, as they are not currently listed on the fee schedule. Private payers, however, may cover:

• 90664 -- Influenza virus vaccine, pandemic formulation, live, for intranasal use

• 90666 -- Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use

• 90667 -- Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use

• 90668 -- Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use

These codes are effective on July 1, 2010, following the six month implementation period which began Jan. 1, 2010. They will appear in CPT 2011.

Use these codes not for the regular flu, but for widespread illness, says Carol Pohlig, BSN, RN,CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. The new codes were created to reflect vaccines that "differ in both formulation and cost, which requires differentiation of products," Pohlig says.

One other new code and one updated code are covered for Medicaid patients in many states (check with your state program to ensure coverage):

• 90644 -- Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza b vaccine, tetanus toxoid conjugate (Hib-MenCY-TT), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use

• 90650 -- Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use

Code 90644 is new; it will be published in CPT 2011, with an implementation date of Jan. 1, 2010. Code 90650 is revised; AMA removed the FDA approval pending indicator from 90650 on Oct.16, 2009. The FDA approval pending indicator will be removed with CPT 2011.

Last word: Don't forget to add the appropriate administration and diagnosis codes to these claims. For complete guidance on coding for Medicare-covered adult vaccines, reference "Keep Infectious Diseases at Bay With  This 1-2-3 Approach To Vaccinations" in Internal Medicine Coding Alert, Vol. 13, No. 2.