Internal Medicine Coding Alert

Published on Mon Oct 25, 2010 PDF

Answer 4 questions to keep your claims on track during flu season.

With flu season getting underway, it's time to brush up on coding for patients who visit your office for vaccines. Ask yourself these four questions to ensure you correctly narrow down your options.

Are You Coding H1N1 Alone, or In Combination?

Some patients ask to be vaccinated against H1N1 alone, but others want protection from all strains.

Last year, you coded for H1N1 alone by reporting 90663 (Influenza virus vaccine, pandemic formulation). "'Pandemic' means it's formulated against a strain causing epidemics worldwide," explains Nancy Bishof, MD, a pediatrician in Lexington, Ky.

Beginning in 2011, however, your coding tactic will change. Coders will no longer be reporting 90663 for H1N1 alone because standard flu shots now include the H1N1 vaccine. Code 90663 remains in CPT, but you won't report it.

Note: If you're filing a Medicare claim, report HCPCS code G9142 (Influenza A [H1N1] vaccine, any route of administration) instead of a CPT code (MLN Matters, MM7120, October 22, 2010).

Combination vaccines that protect patients from H1N1 and other strains of influenza fall under codes 90655-90660 (Influenza virus vaccine ...).

Approvals: CPT 2010 includes the "lightning bolt" symbol beside codes 90661-90663 to designate pending FDA approval. The FDA has cleared at least two the vaccines' use in the U.S., so CPT 2011 will list codes 90662 and 90663 as fully approved options. "FDA approval should increase the chances of third-party payment," says Kent J. Moore, manager of healthcare delivery and financing systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

What's the Vaccine Formulation?

All flu vaccine options aren't created equal -- some are split virus, others are live virus. Some are preservative free, others are not. Understanding these distinctions will help you code more accurately

A split virus vaccine consists of a purified antigenic determinant separated from the disease-causing organism. "I describe split vaccines as 'predigested' or 'broken down into little pieces' so the immune system can handle them easier or better," says Bishof. "The split virus vaccine must be used for kids under age 3, and can be used in older kids."

Example: Two split virus flu vaccines are 90657 (Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use) and 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use).

A live virus vaccine contains an attenuated virus, meaning the virus has been altered, so it produces natural immunity but does not produce the disease. Code 90660 (Influenza virus vaccine, live, for intranasal use) represents live flu virus vaccine.

Preservative free is self-explanatory. Some vaccines include such a small, trace amount of preservatives that they meet the FDA's guidelines for "preservative free." These include 90655 (Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use) and 90656 (Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use).

Heads up: The preservative-free vaccine takes longer to produce, which means it's available later in the fall and is more expensive. "Since it's never been proven that mercury causes autism and all the other vaccines kids get are mercury-free, I use the regular flu vaccine in my office," Bishof says. "I send parents who want the preservative-free vaccine to the health department."

How Old Is the Patient?

As noted in the descriptors above, many influenza vaccine codes specify the patient's age. Just because the code doesn't specify an age limit, however, doesn't mean one might not apply.

Example: Report 90662 (Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use) typically for patients age 65 and older. The higher antigen content offers increased protection to older patients. The vaccine may also be appropriate for people with impaired immune responsiveness, who may benefit from an increased antigen dose to more effectively stimulate the needed immune response. This formulation of the influenza vaccine contains four times the hemagglutinin antigen per influenza strain than traditional influenza vaccines.

Does Your Reimbursement Match?

An MLN Matters article (MM7120, October 22, 2010) provided a rundown of the Part B payment allowance for flu immunizations during the 2010-2011 influenza season, effective September 1, 2010. Check your fee schedules and EOBs to ensure your payments are on track:

• 90655 -- $12.398
• 90656 -- $12.375
• 90657 -- $6.297
• 90658 -- $11.368 (for dates of service September 1, 2010 through December 31, 2010)
• 90660 -- $22.316
• 90662 -- $29.213.

Annual Part B deductible and coinsurance amounts do not apply to these charges, the article notes.

Remember: Payers vary on whether they cover some of these vaccines, and the amounts they reimburse. Check your local payer contracts and guidelines for the most accurate information.