Pulmonology Coding Alert

Published on Wed Feb 10, 2016 PDF

Expect to start getting paid for the code by April.

CPT^® added a new influenza vaccine code 90630 manual in 2015, but the code was out of bounds for payment purposes for the 2014-15 flu season. The reason was that the Food and Drug Administration (FDA) had still not granted final approval to the drug by the time flu season began. FDA granted approval mid-flu season.

Good news: You are able to use this code beginning this flu season as the Centers for Medicare and Medicaid Services (CMS) (and presumably other payers) has now geared up to allow payment for this code effective 8/1//2015 to 7/31/2016.

Here’s the Background

The year 2015 saw the introduction of reporting 90630 (Influenza virus vaccine, quadrivalent [IIV4], split virus, preservative free, for intradermal use). The code was not being used much as the vaccine IIV4 was still awaiting FDA approval. Since then, the FDA has approved the vaccine. You should use this code when your physician or another appropriate health care professional in your practice administers a quadrivalent, preservative free influenza vaccine intradermally. This single dose intradermal vaccine is typically given to patients in the 18-64 year age bracket.

Even though the code 90630 was introduced in the beginning of 2015, it carried a lightning bolt sign in CPT^®2015, indicating that the code was still awaiting FDA approval. “The FDA granted approval of the vaccine on December 11, 2014, which was too late to be captured in the 2015 edition of CPT^®,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “The lightning bolt symbol will not appear next to 90630 in the 2016 edition,” adds Moore.

Reason to cheer: CMS, in its Medicare Learning Network (MLN) Matters Article No. MM9357, has updated change request No. 9357 wherein it has provided instructions for Medicare systems to be updated to include influenza virus vaccine code 90630 for claims with dates of service on or after August 1, 2015 (and processed on or after April 4, 2016). The article informs you that your Medicare administrative contractor (MAC) will add influenza virus vaccine CPT^® code 90630 to existing influenza virus vaccine edits and accept it for claims with dates of service on or after August 1, 2015.

Understand the Amount of Reimbursement You Can Expect For 90630

According to CMS, “the Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95% of the Average Wholesale Price (AWP)” except where the vaccine is furnished in a hospital outpatient department. When the vaccine is furnished in the hospital outpatient department, payment for the vaccine is based on reasonable cost.

The Center for Disease Control and Prevention (CDC) has changed some of its recommendations for prevention and control of influenza. In these recommendations, it states that the “vaccine efforts should begin as soon as the seasonal influenza vaccine is available and continue through the influenza season.” To conform to these CDC recommendations, CMS has now changed the payment limit effective date relative to flu season from September 1 to August 1. Accordingly, the payment allowance that CMS has fixed for code 90630 for the 2015-2016 flu season (August 1, 2015, through July 31, 2016) is $23.467.

Remember: Medicare continues to cover many seasonal influenza vaccines without application of coinsurance or the annual Part B deductible. This is true when you are reporting 90630, too.

The MLN Matters article also informs that MACs will hold institutional claims containing influenza virus vaccine CPT^® code 90630 (with dates of service on or after August 1, 2015) that they receive before April 4, 2016.

Once the system changes described in CR9357 are implemented, these institutional claims will be processed and paid. “Unfortunately, neither MM9357 nor the corresponding change request to the MACs references professional claim holding for 90630 received before April 4, 2016,” Moore observes.

Finally, don’t forget to also report an appropriate code for administration of the flu vaccine, since code 90630 only covers the vaccine itself. For Medicare patients, you should use code G0008 (Administration of influenza virus vaccine). For non-Medicare patients, consider an appropriate CPT^® code from the range 90460-90474.

For more information, check the MMS article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9357.pdf and https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html.