Primary Care Coding Alert

Question: The FP's physician assistant (PA) administered a preservative-free intramuscular flu vaccine without pneumonia vaccine to a 16-year-old patient. How should I code this encounter? Ohio Subscriber Answer: Check whether the vaccine had preservatives before coding. You should report 90656 (Influenza virus vaccine, split virus, preservative-free, when administered to individuals 3 years and older, for intramuscular use) for preservative-free vaccines and 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) for supplies with preservatives. Patients who require flu vaccinations from your FP will allow you to report a pair of codes for the service: one for the vaccine and another for the administration. On the claim, report the following: - 90656 for the vaccine - 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the administration - V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza) linked to 90471 and 90656 to provide medical necessity - 780.60 (Fever, unspecified) linked to 99201 to represent the patient's fever and chills.