Pulmonology Coding Alert

CPT^® revises eight codes to reflect dosage, rather than patient age

Are you up to speed on the CPT^® 2017 updates on flu vaccines? Check with your clinical staff too. Changes in 2017 CPT^®  language can easily lead you to miscode if you don’t have a grip on the latest versions. To survive — now you will need to select your vaccine code based on the dosage rather than the age of the patient. Plus, you will have to dig the documentation for viral strains the vaccine works against, the presence of preservatives in the vaccine, and a lot more.

First, Master the New Code For 2017

“Coding for something as simple as an Influenza vaccine has become more complicated, so take the time to learn the appropriate codes to use in your practice,” says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society.

The highlights for 2017 include a new CPT^® code 90674 (Influenza virus vaccine, quadrivalent [ccIIV4], derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use) to report a quadrivalent influenza virus vaccine derived from cell cultures that protect against four different flu viruses, subtypes A and B. You will need to report administration separately.

Rationale: This code was added to differentiate that it is a quadrivalent vaccine. The prior code 90661 (Influenza virus vaccine, trivalent [ccIIV3], derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use) has been revised to show that it is trivalent.

Medicare continues to cover many seasonal influenza vaccines without application of coinsurance or the annual Part B deductible. What about the payment for this new code? “Coinsurance and deductible do not apply to the new influenza code,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “However, payment limitations are in place. Medicare Claims Processing systems could not accept the code prior to January 1, 2017. Institutional claims will be accepted as January 1, 2017, however, the claims will be held and paid once the Fiscal Intermediary Standard System (FISS) changes are implemented on February 20, 2017.”

“It will be a slightly different amount in different areas,” adds Berman. “Payment is more in a city like Miami/New York/San Francisco than in a small town in a rural area.”

Eight Revised Codes Turn from Age Based To Dose Based Descriptors

Another important change you need to know is that CPT^® 2017 revised the official descriptors for the following codes:

• Trivalent influenza virus vaccine codes 90655 to 90658
• Quadrivalent codes 90685 to 90688

Age indications, such as “children aged six to 35 months,” have been removed from the revised descriptors of trivalent influenza virus codes (90655-90658) and quadrivalent influenza virus codes (90685-90688) in CPT^®  2017. There has been a change to revise this age clause to a dose based clause of either 0.25 or 0.5 ml. dose.

The rationale for the change is to better define the vaccinations provided and further encourage reference to the product’s prescribing information. Here are the codes as they stand as of now:

• 90655 (Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use)
• 90656 (…0.5 mL dosage, for intramuscular use)
• 90657 (…split virus, 0.25 mL dosage, for intramuscular use)
• 90658 (…split virus, 0.5 mL dosage, for intramuscular use)
• 90685 (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use)
• 90686 (… 0.5 mL dosage, for intramuscular use)
• 90687 (… 0.25 mL dosage, for intramuscular use)
• 90688 (…0.5 mL dosage, for intramuscular use)

Get an Idea of the Impact

Now that the descriptors rely on dosage specification instead of age, you can choose the codes with a greater clarity. The age of a patient may or may not relate with other physical parameters such as weight, and most drugs in children are administered according to the weight of the child rather than the age.

Now, you can report 90685 irrespective of the age if your provider decides on a 0.25 mL dosage of the vaccine. Earlier, it would have been difficult to get your claim through if your provider gave a lesser dose to an older person. This revision also takes care of your coding dilemma in the past if your provider chose to give a larger, weight-appropriate dose to an obese 10 year-old patient.

Remember:  These codes only cover the specific vaccine. So, you will need to report an additional appropriate code for administration of the flu vaccine. For Medicare patients, you may bill the code G0008 (Administration of influenza virus vaccine). However, for non-Medicare patients, you will have to pick the applicable CPT^® code from the code range 90460-90474.

Don’t Forget to Report Physician Counseling

If the patient is younger than 18 years, and your provider gives him or his family member a face-to-face counseling session along with the vaccine administration, CPT^®  has just the codes for you. Here are the two codes you could choose from, depending on the number of vaccines your patient receives:

• 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered)
• +90461 (…each additional vaccine or toxoid component administered [List separately in addition to code for primary procedure])

The word “component” in these code descriptors refers to all antigens in a vaccine that prevent disease caused by one organism and multi-valent antigens or multiple serotypes of antigens against a single organism are considered to be a single component of vaccine. Combination vaccines contain multiple vaccine components.

Remember: Report these codes only when the provider does face-to-face counseling during the administration of the vaccine.

Services sans counseling: If your provider administered the vaccination to a patient 18 years old or less without counseling, you would report appropriate non-counseling codes for immunization administration, 90471-90474.

Example: Your pulmonologist administers Fluzone intramuscularly to a two year old, along with counseling to the parent(s) regarding the uses and adverse effects of the vaccine. He uses a 0.25mL single dose pre-filled syringe containing a quadrivalent, split virus inactivated influenza virus vaccine for intramuscular use. It is free of preservative and thimerosol.

What to report: You may choose from six codes (90685-90688, 90672, 90674) for a quadrivalent split virus vaccine your provider administered intramuscularly. However, the keyword ‘preservative free vaccine’ will narrow your choice to reporting two codes. Since the dose was 0.25mL, you will choose 90685 for the vaccine. Earlier, too, you would have chosen the same code, although on the pretext that the child fits the code descriptor age parameter of 6-35 months. As for the administration, you would choose 90460 since your pulmonologist also counseled about the vaccine.

“Fluzone trivalent is only available in high-dose for patients greater than 65 years old; all other Fluzone products are quadrivalent,” says Pohlig.

Final takeaway: “Be careful not to confuse the fact that although the CPT^® descriptors have changed to remove the age limitations, the clinical recommendations for age indicated usage have not changed,” says Pohlig.

Note: For more information about the 2016-2017 recommended patient guidelines, please refer https://www.cdc.gov/flu/about/qa/vaxsupply.htm.