Pediatric Coding Alert

To ethically recoup all your deserved pay for flu immunizations, check that you're following four best practices.

A pediatric practice recently asked Pediatric Coding Alert for money-making tips as staff gear up for flu season. "In the past, we have had difficulty in just breaking even for the cost of the influenza vaccine," wrote the subscriber. "How can we be reimbursed by private insurances at the best rate of return?" she asked.

Here's how to clear several coding pitfalls that can sink flu vaccination payments. "Make sure you code correct route, correct product, correct ICD-9," says Cathy Gray, RHIT, CCS, CPC-I, CCC, CGIC, with Henry Ford Health System in Detroit.

Look at the manufacturer's box to verify that you're reporting the correct product code for the influenza product the patient is receiving. Preservative-free products, including Fluzone No Preservative, Fluvirin Preservative-Free,and Fluarix, cost more and should reimburse at a higher rate than non-preservative-free products (Fluzone and Fluvirin). Intranasal product FluMist (90660, Influenza virus vaccine, live, for intranasal use) pays the most ($22.316 using 2008 rates).

Example: If a patient received Fluzone No Preservative Pediatric and you incorrectly used the regular product code (90657, Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use), rather than the preservative-free product code (90655, Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use), you would lose $10 in reimbursement. The payment allowance for the preservative-free pediatric product code (90655) is $16.879 compared to $6.609 for the same-age approved regular product code (90657).

The difference between the older-set preservative and preservative-free products codes, such as for Fluvirin Preservative-Free and Fluvirin, is almost $5. Code 90656 has an allowance of $18.198, while 90658's allowance is $13.128.

Figures based on 95 percent of the 2008 Average Wholesale Price. CMS will release the 2009 rates Sept. 1 at www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp. Your payment rates will vary based on your specific contracts with each payer. The differences between the vaccine product types referred to in the article should be comparable.

Choose the exact product code based on the patient's age. The older-age vaccine product codes (90656, Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use; and 90658, Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) pay more than their youngerage counterparts (90655, Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use; and 90657, Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use).

Not paying attention to the child's age could cost you more than $6. Suppose a 5-year-old patient receives Fluzone and you incorrectly assign 90657, rather than the 3 years and older influenza virus vaccine code 90658. Your allowance would be $6.61 less than if you had used the correct code. The allowable for 90658 is $13.218 compared to $6.609 for 90657.

If a patient is receiving the intranasal influenza vaccine at the same time as an injectable vaccine, code the injectable as the first vaccine (90465 or 90471), stresses Joel Bradley, MD, FAAP, medical director of one of Tennessee's managed Medicaid health plans and a general pediatrician in Franklin. "Code the oral/intranasal vaccine after (90468 or 90474)."

Difference: Reversing the order could cost you almost $6. The initial oral codes (90467, Immunization administration younger than age 8 years [includes intranasal or oral routes of administration] when the physician counsels the patient/family; first administration [single or combination vaccine/toxoid], per day; and 90473, Immunization administration by intranasal or oral route; one vaccine [single or combination vaccine/toxoid]) pay less than the initial injectable codes (90465, Immunization administration younger than 8 years of age [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels the patient/family; first injection [single or combination vaccine/toxoid], per day; and 90471, Immunization administration [includes percutaneous, intradermal,subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]).

Example: A 6-year-old patient receives the hepatitis B vaccine and the intranasal influenza vaccine. You should report the hepB vaccine shot (90744, Hepatitis B vaccine, pediatric/adolescent dosage [3 dose schedule], for intramuscular use) as the initial administration with 90465 or 90471. Report the additional intranasal vaccine with +90468 (... intranasal ... each additional administration [single or combination vaccine/toxoid], per day [List separately in addition to code for primary procedure]) or +90474 (... intranasal ... each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]).

Reporting the initial injection (90471, 0.58 RVUs) and subsequent oral vaccine administration (+90474, 0.25 RVUs) pays $29.94 using the 2009 Medicare Physician Fee Schedule as a benchmark for private payers' fee schedules. But reporting the initial oral vaccine (90473, 0.38 RVUs) and the subsequent initial injection (+90472, 0.29 RVUs) pays approximately $24.16 -- a difference of $5.78.

Use the administration code set that represents the patient's age and physician (or practicing nurse practitioner or physician assistant) counseling. If you're thinking, "Why bother since the sets pay the same?" -- think again.

Surprise: Some well-known national payers still pay more for 90465-+90468 than for the comparable 90471- +90474 code. The Medicare Physician Fee Schedule assigns the same relative value units to both vaccine administration code sets. When CPT 2005 introduced the new vaccine administration code set (90465-+90474) and at the same time almost doubled relative value units for the existing code set, many managed care organizations entered the new codes in their systems with those values, but didn't update the original codes' (90471-90474) values.

People who are using 90465-+90465 usually find an average difference of $3, according to national customer data compiled by the Physician's Computer Company (www.PCC.com).