Part B Insider (Multispecialty) Coding Alert

Published on Sat Sep 12, 2009 PDF

Code 488.1 does not guarantee a confirmed dx.

Swine flu has made an early arrival in several states and in your 2009 preventive and sick coding. To avoid denials for H1N1 vaccination administration, you'll have to check which of three administration code options your major payers want.

"Some payers want you to use the new code, others want you to use Medicare's code, and others want you to use the regular vaccine administration codes," says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Best bet: Create a spreadsheet that lists which H1N1 vaccine administration code each of yourpayers requires. Here are the options: The AMA fast-tracked a CPT code for vaccine administration specifically for H1N1, Tuck says.

Code 90470 (H1N1 immunization administration [intramuscular] [intranasal] including counseling when performed]) is effective immediately.

Part B: Medicare had already created G9141 (Influenza A [H1N1] immunization administration [includes the physician counseling the patient/family]), which you should use when billing Part B.

"It's very important that when you bill Medicare Fee-For-Service, that you use the G code," noted  CMS's Stewart Streimer during an Oct. 6 Physicians Open Door Forum (ODF). "Do not use the newly-developed CPT code that's just been announced by the AMA," he said.

In addition, some non-Medicare payers have requested practices to bill using G9141. You should check with each payer before you bill the vaccine.

You should charge for the administration with 90470, G9141,  or 90465-90474 (Immunization administration younger than 8 years of age [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels he patient/family...), depending on your payer's preference.

The amount can be no higher than your state's specific allowable for vaccine administration. "This is generally $16-$20 depending on the state," says Tuck.

Just because ICD-9 2010 provides a code for H1N1 doesn't mean you should automatically use it. The 2009 coding guidelines instruct you to code only confirmed cases of novel H1N1 influenza virus (H1N1 or swine flu, code 488.1).

Rule: Coding should be based on the provider's diagnostic statement that the patient has novel H1N1 (H1N1 or swine flu) influenza. If the provider records "suspected or possible" H1N1 influenza, you should instead use the appropriate influenza code from category 487.x.