Pulmonology Coding Alert

Keep track of the administration codes to pinpoint vaccine codes.

More often than not you may find yourself at crossroads while coding flu shot services your pulmonologist or nurse provides, as you’ll encounter different payment rules for Medicare and other private payers. Follow our experts’guidance in reporting the correct codes, and get the best out of your reimbursement for flu shot administration. 

Multiple factors decide the correct vaccine code

Keep a sharp lookout for these three conditions when in doubt of the correct choice of flu vaccine.

• You have to select between 90656 (Influenza virus vaccine, trivalent, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use) and 90658 (Influenza virus vaccine, trivalent, splitvirus, for use in individuals 3 years of age and above, for intramuscular use) for all patients 3 years old and above depending upon the presence of preservatives in the vaccines. 
• You can code either 90655 (Influenza virus vaccine, split virus, preservativefree, for children 6-35 months of age, for intramuscular use) or 90657 (Influenza virus vaccine, trivalent, split virus, forchildren 6-35 months of age, for intramuscular use) for patients between 6 and 35 months depending upon the presence of preservatives in the vaccines.

As you can see, you have to choose between preservative-free and regular vaccine. You will code 90656 and 90655 if you’re provider uses preservative-free vaccines, and then you will code 90658 and 90657 for regular vaccines. “To determine whether or not the vaccine contains preservatives, look at the product insert for inclusion of thimerosal (a mercury-based preservative). If the product contains <1(µg Hg/0.5 mL) mercury content from thimerosal, it is preservative-free. Typically, single dose vials or pre-filled syringes are preservative free. Multi-dose vials contain thimerosal,” explains Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania. You can also identify the product by name in the CDC vaccine supply list, available at http://www.cdc.gov/flu/about/qa/vaxsupply.htm. 

Note: Note any exceptions such as intranasal vaccines. If your physician administered an intranasal vaccine, then you should report 90660 (Influenza virus vaccine, live, for intranasal use).

Capture Other Services Provided for Correct Administration Codes

You have to append an administration code to the vaccine code as submission of a flu shot service is a two-code process. You need to choose one of the following administration codes to add to the vaccine code you have chosen in the first step:

• In case of private payers, if the flu shot is the primary vaccine, submit code 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]). If you administered the flu shot in addition to another primary vaccine, you should submit 90471 with +90472 (… each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]). For administration of intranasal vaccine, you should code 90473 (Immunization administration by intranasal or oral route; one vaccination [single or combination vaccine/toxoid]) or +90474 (… each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]), depending on the number of vaccines your physician administers.
• For Medicare and those that follow Medicare rules, you should code G0008 (Administration of influenza virus vaccine) to bill for flu shot administration. 

Note: You cannot report G0008, 90471 or 90473 with a nurse visit (99211) under the National Correct Coding Initiative (CCI) bundling edits. If the patient sees the physician for a reason other than the flu shot, you may report a separate E/M, but it will require modifier 25(Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), as appropriate.

Prove Medical Necessity

You should prove the medical necessity of vaccination by attaching code V04.81 (Need for prophylactic vaccination and inoculationagainst certain viral diseases; other viral diseases; influenza) to both the vaccine code and the administration code. Some payer requirements specify that patients with an increased risk for the flu, such as those suffering from chronic obstructive pulmonary disease, COPD, are identified separately with additional diagnosis codes that identify the cause for increased risk (e.g., 496, Chronic airway obstruction, not elsewhere classified).

Open Other-E/M-Services Lock With a Modifier 25 Key

For instance, a 64-year-old patient under Medicare approaches a doctor for a flu shot displaying asthma symptoms. He receives an intramuscular, regular vaccine, and a level-three established patient E/M service to evaluate and treat his asthma condition. Report G0008 and 90658 linked to V04.81 for the flu shot, and 99213-25 (Office or other outpatient visit for the evaluation and management of an established patient…) linked to the appropriate diagnosis code (for example, 493.10, Intrinsic asthma, unspecified) for the E/M visit. 

Then append modifier 25 to 99213 to ensure payment of both services. 

Co-Pay is Out of the Window

In previous years, you may have encountered a lot of issues regarding co-pay or co-insurance in administration of flu shots. Some insurance plans covered the flu shot wholly, some partially and, as such, confusion reigned. As of this year, due to the Affordable Care Act, most plans cover preventive care (as represented by the flu shots), and no deductible, co-pay or co-insurance is required.

All patients will be allowed one flu shot per season (fall/winter). Medicare patients are also exempt from any payment whatsoever for a flu shot if they visit the provider for the express purpose of getting vaccinated. Medicare will cover additional seasonal influenza virus vaccinations separately if found medically necessary.