Internal Medicine Coding Alert

Published on Wed Dec 19, 2012 PDF

Use this refresher to keep age-group coding accurate.

Did you know Medicare covers certain vaccines for all beneficiaries, and additional vaccines or doses based on medical necessity or risk?

Read on for need-to-know vaccine coding tips,including the three types of codes you should always report with each vaccine administration: diagnosis, administration, and product.

1: Help Banish the Influenza Virus

Coverage: All Medicare beneficiaries may receive a covered influenza vaccine dose once per flu season (in the fall or winter).

Twice per year: While Medicare pays for one vaccination per flu season, a beneficiary could receive the flu vaccine twice in a calendar year for two different flu seasons and Medicare will reimburse the provider for each,according to the Medicare Part B Immunization Billing reference chart at www.cms.hhs.gov/mlnproducts/downloads/qr_immun_bill.pdf. For instance, a beneficiary could receive a covered flu vaccination in January 2010 for the 2009-2010 flu season and another covered flu vaccination in November 2010 for the 2010-2011 flu season.

Twice per season: Medicare may provide additional flu shots if medically necessary. Reasons a beneficiary may receive more than one covered flu shot per season include a deficiency of the original dose or a product recall, indicates Quinten A. Buechner, MS, M.Div, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Diagnosis: If the patient is receiving only the influenza vaccine during the encounter, report:

• V04.81 -- Need for prophylactic vaccination and inoculation against certain diseases, influenza.

Administration: The correct code for administering the influenza vaccine when reporting to Medicare is:

• G0008 -- Administration of influenza virus vaccine.

Tip: Don’t overlook adding the administration code to the claim form for any vaccine administration. “There are a lot of carriers who will not allow the administration code to be billed after the appeal time has run out, so if the administration charge is not captured in time, it will not be able to be recovered,” warns Kris Cuddy, CPC, CIMC, an independent consultant based in DeWitt, Mich.

Product: Here’s where the coding gets tricky -- the product codes vary based on whether the dose is preservative free, who you are administering it to, and whether it is delivered via injection or a mist. The breakdown is as follows:

• 90655 -- Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use

• 90656 -- Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use

• 90657 -- Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use

• 90658 -- Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use

• 90660 -- Influenza virus vaccine, live, for intranasal use.

Thus, if you were administering a flu shot to an adult via injection from a ten-dose (preservative-free) vial, you would report 90656 for the product code, while 90660 would apply to an adult receiving the FluMist.

2: Stamp Out Pneumococcal Disease

Coverage: All Medicare beneficiaries may receive a covered dose of the pneumococcal (Pc) vaccine once in a lifetime.

Extra doses: You may be reimbursed for providing additional Pc vaccinations based on risk if at least five years have passed since the beneficiary last received a previous dose. Individuals at high-risk include people age 65 and older, diabetics, those with chronic lung, heart, or kidney disease, and patients with other immunosuppressive disorders.

Good to know: If a beneficiary is uncertain about whether he received a dose in the past five years, you may administer the vaccine and Medicare will cover the revaccination, states the Medicare Part B Immunization Billing chart at www.cms.hhs.gov/mlnproducts/downloads/qr_immun_bill.pdf.

Diagnosis: Watch out for vaccination doubling up that will require switching from one ICD-9 V code to another.The appropriate diagnosis code to go along with the solo Pc vaccine is V03.82 (Other specified vaccinations against single bacterial diseases, streptococcus pneumoniae [pneumococcus]). If you are also administering the flu vaccine (in addition to Pc), however, at the same encounter, instead report V06.6 (Need for prophylactic vaccination and inoculation against combinations of diseases, streptococcus pneumoniae [pneumococcus] and influenza.)

Administration: For administration of the vaccine, attach the relevant G code to the claim:

• G0009 -- Administration of pneumococcal vaccine. When you administer both the flu virus and the Pc vaccine at the same visit, Medicare will pay for both administration fees -- G0008 and G0009 -- so don’t forget to report both.

Product: To determine which product codes are accurate, you’ll have to ascertain the make-up of the vaccine, conjugate or polysaccharide. If you are unsure, check the product insert. Then report the appropriate product code:

• 90669 -- Pneumococcal conjugate vaccine, 7 valent, for intramuscular use

• 90732 -- Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use.

3: Limit the Spread of Hep B

Coverage: Medicare will cover hepatitis B virus (HBV) vaccinations only for beneficiaries it deems “medium (or intermediate) to high risk,” according to the vaccination guide.

Medium risk patients include workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work and employees at homes for the mentally handicapped.

People at high risk for the disease include persons who live in the same household as an HBV carrier, homosexuals, users of illicit injectable drugs, individuals with hemophilia (V83.xx) who received Factor VIII or IX concentrates, and people with end-stage renal disease (ESRD, 585.6) or chronic kidney disease (585.6) stage V requiring chronic dialysis.

Exception: Persons in the above-listed groups would not be considered at high or intermediate risk of contracting HBV infection if they have laboratory evidence positive for HBV antibodies, shares Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health’s Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.

Diagnosis: The correct V code to accompany the HBV vaccine is:

• V05.3 -- Need for prophylactic vaccination and inoculation against single diseases, viral hepatitis.

Administration: The administration code for the HBV vaccine in an office setting is:

• G0010 -- Administration of hepatitis B vaccine.

Product: Watch your step with the HBV product codes, which depend on the patient’s age, medical condition, and the number of doses. Select from the following:

• 90740 -- Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use

• 90743 -- Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use

• 90744 -- Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use

• 90746 -- Hepatitis B vaccine, adult dosage, for intramuscular use

• 90747 -- Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use.

Resources: For complete details on the groups Medicare considers to be at highest risk for the above infections, consult The Guide to Medicare Preventive Services at www.cms.hhs.gov/mlnproducts/downloads/psguid.pdf.