Pulmonology Coding Alert

'Tis the season: Patients have been heading to the office for their annual flu vaccinations, and coders should prepare by boning up on the different coding methods for these services.

Choosing the right flu shot vaccination codes is a two-step process that is governed by different rules depending on the payer. Check out this plan that will make your flu shot coding a cakewalk.

Patients who require flu vaccinations from your pulmonologist will allow you to report a pair of codes for the service: one for the vaccine, and another for the administration. You'll choose one of the following vaccine codes on your flu vaccination claim, says Sheldrian LeFlore, CPC, revenue management educator with The Coding Group in Carlsbad, Calif:

The difference: Use 90656 if the pulmonologist administers a preservative-free vaccine; reserve 90658 for vaccines containing preservatives, LeFlore says.

If your office has preservative-free vaccines, expect patients to ask for them. Patients are becoming more discerning when choosing a vaccine; as a result, more of them request the preservative-free vaccine, says Karen Deardurff, CPC, coder at Saint Joseph Physician Network in Mishawaka, Ind.

When choosing the vaccine code, make sure you have the right one. "It is important not to guess" whether a vaccine has preservatives or not, because this could result in a financial loss for the practice as the preservative-free vaccine costs more than the standard one, LeFlore says. Conversely, you do not want to receive increased payment for reporting 90656 when the practice provides a standard vaccine to the patient.

If you are unsure about the contents of the vaccine, the packaging it came in will help you answer the preservative question. Or you can consult the vaccine manufacturer to check if the product has preservatives.

Then, be sure to "educate physicians on documenting this information in the medical record. Ultimately, the medical record is the source document" for choosing the code, LeFlore says.

Tip: The lot number should contain the vaccine brand name -- such as AfluaXXXXX. This term represents Fluarix, a preservative-free product prepared in single-dose vials that have been processed to remove almost all of the thimerosal. Documentation of the brand and lot number (in addition to the pertinent clinical data, such as location given and patient's response) will justify your 90656 claim.

When selecting a code for the work the physician performs while administering the vaccine, remember the different rules for Medicare and private payers.

For private carriers, report the administration with 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) if the flu shot is the sole vaccine the pulmonologist injects. If the physician administers multiple vaccines (i.e., two or more injection sites) in the same visit, report +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) for each immunization beyond the first, LeFlore says.

Example: A patient with commercial insurance receives a flu shot with preservatives and a pneumonia vaccine during the same encounter. On the claim, report the following codes:

• 90658 for the flu vaccine supply

• 90471 for the administration

• 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to 2 years or older, for subcutaneous or intramuscular use) for the pneumonia vaccine supply

• +90472 for the administration.

Medicare requires G code: When the pulmonologist provides a Medicare patient with flu vaccine, coding varies slightly. You'll still choose 90656 or 90658 for the supply, but code the administration with G0008 (Administration of influenza virus vaccine) if the physician provides the patient no other physician fee schedule service that day, Deardurff says.

If the pulmonologist provides a Medicare patient with a flu vaccine and a pneumonia vaccine during the same encounter, choose G0009 (Administration of pneumococcal vaccine) for the pneumonia vaccine.

So coding for a flu/pneumonia vaccine combination for a Medicare patient would look like this:

• 90658 for the flu vaccine supply

• G0008 for the administration

• 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to 2 years or older, for subcutaneous or intramuscular use) for the pneumonia vaccine supply

• G0009 for the administration.

If the notes indicate that the pulmonologist gave the patient an intranasal vaccine instead of an injection, your coding must change. In these instances, code the supply with 90660 (Influenza virus vaccine, live, for intranasal use) instead of 90656 or 90658. Use this code for both Medicare and private carriers, LeFlore says.

As for the administration, you'll choose 90473 (Immunization administration by intranasal or oral route; one vaccine-[single or combination vaccine/toxoid]) for private carriers. Code any additional intranasal vaccines with +90474 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]).

If you treat a Medicare patient with the intranasal vaccine, report G0008 for the administration and 90660 for the supply, Deardurff says.

The last step in coding flu shot encounters is choosing the proper ICD-9 code. That should not be too hard, because there are only two codes that you can use for the service, LeFlore says.

Option 1: If the pulmonologist is administering a flu vaccine, but no pneumonia vaccine, during the session, you'll include V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza) on the claim.

Option 2: "The only time you should not use V04.81 for a flu shot is when a flu vaccine and a pneumonia vaccine are given during the same session and the insurer instructs you to use the combination ICD-9," Deardurff says. When the physician provides both vaccines in the same session, use ICD-9 code V06.6 (Need for prophylactic vaccination and inoculation against combinations of diseases; streptococcus pneumoniae [pneumococcus] and influenza) instead.