Internal Medicine Coding Alert

Published on Tue Dec 18, 2012 PDF

Coding differs for intranasal vaccine, ‘shot’ immunization

’Tis the season: Patients will soon be heading to the office for their annual flu vaccinations, and coders should prepare by boning up on the different coding methods for these services.

Choosing the right flu shot vaccination codes is a two-step process that is governed by different rules depending on the payer. Check out this four-step plan that will make your flu shot coding a cakewalk.

Step 1: Answer Preservative Question, Choose Vaccine Code

Patients who require flu vaccinations from your internist will allow you to report a pair of codes for the service: one for the vaccine, and another for the administration. You’ll choose one of the following vaccine codes on your flu vaccination claim:

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

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

The difference: Use 90656 if the internist administers a preservative-free vaccine; reserve 90658 for vaccines containing preservatives, says Sheldrian LeFlore, CPC, revenue management educator with The Coding Group in Carlsbad, Calif. "Most doses contain preservatives, but preservative-free doses are becoming more readily available," she says.

If your office has preservative-free vaccines, expect patients to ask for them. Patients are becoming more discerning when choosing a vaccine; as a result, more of them request the preservative-free vaccine, says Karen Deardurff, CPC, coder at Saint Joseph Physician Network in Mishawaka, Ind.

"Preservative-free is in high demand but low in supply. Doctors’ offices are allotted only a certain amount of it each flu season," she says.

When choosing the vaccine code, make sure you have the right one. "It is important not to guess" whether a vaccine has preservatives or not, as this could result in claim denial, LeFlore says.

If you are unsure about the contents of the vaccine, its packaging may help you answer the preservative question. Or you can consult the vaccine manufacturer to check if the product has preservatives. Then, be sure to educate physicians on documenting this in the medical record.

"Ultimately, the medical record is the source document" for choosing the code, LeFlore says.

Step 2: Select Admin Code Based on Payer

When choosing a code for the work the physician performs while administering the vaccine, remember the different rules for Medicare and private payers.

For private carriers, report the administration of a vaccine by injection with 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) if the flu shot is the sole vaccine the internist injects.

If the physician administers multiple vaccine injections in the same visit, report +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) for each immunization beyond the first, LeFlore says.

Example: A patient with commercial insurance receives a flu shot with preservatives and a pneumonia vaccine during the same encounter. On the claim, report the following codes:

• 90658 for the flu vaccine supply

• 90471 for the administration of the first vaccine injection (flu)

• 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosupressed patient dosage, when administered to 2 years or older, for subcutaneous or intramuscular use) for the pneumonia vaccine supply

• 90472 for the administration of the second vaccine injection (pneumonia).

Medicare requires G code: When the internist provides a Medicare patient with flu vaccine, coding varies slightly.

You’ll still choose 90656 or 90658 for the supply, but code the administration with G0008 (Administration of influenza virus vaccine), Deardurff says.

If the internist provides a Medicare patient with a flu vaccine and a pneumonia vaccine during the same encounter, choose G0009 (Administration of pneumococcal vaccine) for the pneumonia vaccine administration.

So coding for a flu/pneumonia vaccine combination for Medicare patient would look like this:

• 90658 for the flu vaccine supply

• G0008 for the administration of the flu vaccine

• 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosupressed patient dosage, when administered to 2 years or older, for subcutaneous or intramuscular use) for the pneumonia vaccine supply

• G0009 for the administration of the pneumonia vaccine.

Step 3: Double-Check Administration Method

If the notes indicate that the internist gave the patient an intranasal vaccine instead of an injection, your coding must change. In these instances, code the supply with 90660 (Influenza virus vaccine, live, for intranasal use) instead of 90656 or 90658.

Use this code for both Medicare and private carriers, LeFlore says.

As for the administration when the patient receives no other vaccine administration that day, you’ll choose 90473 (Immunization administration by intranasal or oral route; one vaccine-[single or combination vaccine/toxoid]) for private carriers.

If the patient receives the intranasal vaccine in addition to an injected vaccine, code the intranasal vaccine administration with +90474 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]). If you treat a Medicare patient with the intranasal vaccine, report G0008 for the administration and 90660 for the supply, Deardurff says.

Step 4: Choose ICD-9 Code for Vaccination

The last step in coding flu shot encounters is choosing the proper ICD-9 code. That should not be too hard, because there are only two codes that you can use for the service, LeFlore says.

Option 1: If the internist is administering a flu vaccine but no pneumonia vaccine during the session, you’ll include V04.81 on the claim. So if the physician injects a Medicare patient with a flu vaccine with or without preservatives, you would report V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza) linked to both the supply code (90656 or 90658) and the administration code (G0008) to prove medical necessity for the visit.

Option 2: "The only time you should not use V04.81 for a flu shot is when the physician gives a flu vaccine and a pneumonia vaccine during the same session," Deardurff says. When the physician provides both vaccines in the same session, use code V06.6 (Need for prophylactic vaccination and inoculation against combinations of diseases; streptococcus pneumoniae [pneumococcus] and influenza) instead.

This code is for use on claims to Medicare and commercial payers, Deardurff says.

So when the internist administers flu and pneumonia vaccine during the same session to a patient with private insurance or Medicare insurance, be sure to link V06.6 to all of the codes.