The following is an excerpt from the October 2009 AAP Coding Newsletter
The H1N1 influenza virus vaccine (swine flu) product will be furnished to providers by the federal government for all patients regardless of insurance. It is expected that the shipment of the vaccine product will also include the necessary supplies (e.g., syringes, needles, sharps containers, alcohol swabs). The distribution of the vaccine will be determined by each state and may include physicians, pharmacies, public health departments, and schools.
The American Academy of Pediatrics (AAP) is querying large commercial payers to discern their policies addressing billing of and coverage for immunization administration of the H1N1 vaccine product in the physician’s office. Most of major payers that have responded to the AAP have indicated that they will pay physicians for the administration of the vaccine. However, because the vaccine product is provided at no cost, some payers are trying to determine how they will require the reporting of the service.
Coding the Immunization Administration
Effective immediately, the H1N1 influenza vaccine should be reported as follows:
90470 H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
Medicare Resource-Based Relative Value Scale (RBRVS) values are currently being established for code 90470. Toward that end, the American of Academy of Pediatrics (AAP) has sent a letter to major carriers urging them to pay no less than current Medicare rates for the administration. You can access that letter at www.aap.org/moc/reimburse/privatesector.htm.
Coding the H1N1 influenza virus vaccine
Effective immediately, the H1N1 influenza vaccine product should be reported with revised CPT code 90663 -- Influenza virus vaccine, pandemic formulation, H1N1.
The AMA instructs physicians to report CPT code 90663 with a “0” charge in conjunction with the administration code 90470. However, many billing software systems are unable to process claims with services that have a “0” charge and will require that only the administration (ie, code 90470) be reported. Watch for specific reporting guidelines from your major payers.
The Medicare program will require reporting the administration of the H1N1 Influenza virus vaccine with new Healthcare Common Procedure Coding System (HCPCS) code G9141 (influenza A, H1N1, immunization administration). The payment will be the same as what is currently reimbursed under the program for the administration of the seasonal influenza virus vaccine. Because some state Medicaid programs follow Medicare policies, they may also require reporting with code G9141.
All services should be reported with the International Classification of Diseases, 9th Revision, Clinical Modifications (ICD-9-CM) code V04.81 (need for prophylactic vaccination and inoculation against influenza).
Reporting both the H1N1 vaccine and the seasonal influenza virus vaccine when administered on the same day of service
Again, reporting will be payer specific. The appropriate seasonal influenza virus vaccine product code (90655, 90656, 90657, 90658, and 90660) should be reported. An immunization administration code should be reported in association with the vaccine product administered. If required by the payer, report code 90663 for the H1N1 vaccine product. If the payer does not require that code 90663 be reported, only code 90470 would be reported for the administration of the H1N1 vaccine.
According to the American Medical Association’s (AMA) Fact Sheet on Reporting for H1N1 (found at www.ama-assn.org/ama/pub/h1n1/resources/cpt-coding/) code 90470 should be reported for the initial immunization administration and either code 90466, 90467, 90472 or 90474 should be reported for the additional immunization administration.
Reporting services provided to patients covered under the Vaccines for Children Program (VFC)
Services should be reported based on the policies as mandated by the Medicaid program in your state. Check with your state program for the specific criteria for reporting the immunization administration.
Check updates of coverage by commercial payers
It is anticipated that most commercial payers will be notifying all participating physicians of their coverage policy. You can also access up to date information regarding coverage and billing requirements of major payers on the AAP website at www.aap.org/. Research the policies of your major payers on their individual websites.
Updated October 6, 2009. Reprinted with permission from the American Academy of Pediatrics.