Ob-Gyn Coding Alert

From immunizations to diagnoses, get the lowdown on flu patients.

It’s that time of year again — when patients present to the office requesting flu shots or evaluations of possible flu diagnoses. Although some influenza visits are fairly straightforward, chances are strong that you’ll have a few questions about how to appropriately collect for your flu shot and flu diagnosis services. The following three tips can help you eliminate payment woes before they begin.

Tip 1: Two Strains Could Equal Dual Codes

Performing a flu test is standard practice for physicians, but when you have to administer two tests on the same date, your coding can get tricky. If you perform a rapid flu test for strains A and B at the same visit and the assays provide two separate results (i.e., a result for influenza virus A and a result for influenza virus B), it would be appropriate and many insurers will allow you to report 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; influenza) twice. “When two units of code 87804 are submitted, modifier 59 (Distinct procedural service) may be appended to the second unit to indicate that the two results represent separate services (e.g., 87804 and 87804-59),” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Some state Medicaid programs require you to follow Medicare modifier guidelines and append modifier QW (CLIA-waived test) to 87804. To keep coding uniform, many practices use modifier QW regardless of payer.

Therefore, if you use a product that differentiates between influenza A and B and the physician documents both results, you should report 87804 twice or put “2” in the units of service box on the claim form, whichever the payer requires or recognizes. For payers that do not automatically recognize two units of 87804 and deny the second charge as a duplicate, use modifier 59 (Distinct procedural service) on the second 87804 entry. For example, you might report 87804-QW with one unit and 87804-QW-59 for the second unit to these insurers.

Tip 2: E/M with Flu Shot Requires Modifier

Although most of your flu shot visits involve just a few minutes of the doctor’s time, you’ll also experience scenarios when the doctor has to perform a separate, complete E/M visit in addition to the flu shot. In these cases, a modifier will be your friend.

Here’s why: According to Correct Coding Initiative (CCI) edits, E/M office or inpatient codes are bundled into the vaccine administration codes 90460, 90471 and 90473.

The modifier indicator for most of these bundles is “1,” which indicates that you can separate the codes using an appropriate modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). However, the exception to this rule is code 99211. CCI edits won’t allow you to report 99211 for the same patient on the same date as a vaccine administration.

To support the medical necessity of the vaccine, you will need to report the ICD-10 code Z23 (Encounter for immunization).

Tip 3: Look to J10 and J11 for Flu Dx

You may have the ICD-9 codes for influenza committed to memory, but like all of your other diagnosis codes, you’ll have to replace them with dates of service on or after Oct. 1, now that ICD-10 is in effect.

Under ICD-10, you should report either J10 (Influenza due to other identified influenza virus) or J11 (Influenza due to unidentified influenza virus), depending on whether the “unspecified” virus is an “other identified” or “unidentified” virus. As with ICD-9, both J10 and J11 further expand into a fourth digit classification based on the presence or absence of pneumonia, other respiratory manifestations (such as laryngitis, pharyngitis, and upper respiratory infections), gastrointestinal manifestations, or other manifestations such as encephalopathy, myocarditis, or otitis media.

For example, J10 under ICD-10 expands into the following four codes using a fourth digit expansion:

• J10.0 (Influenza due to other identified influenza virus with pneumonia)
• J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations)
• J10.2 (Influenza due to other identified influenza virus with gastrointestinal manifestations)
• J10.8 (Influenza due to other identified influenza virus with other manifestations).

Code J10.0 further expands into five digits based on the type of pneumonia involved or the manifestation, so carefully select your code before billing for the diagnosis.