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Coding guidelines for seasonal Influenza, 2009 H1N1 (swine flu) and Pneumococcal vaccines


For current updates please check 'Flu vaccine - updates for the year 2011 - 2012'

Influenza - An acute febrile highly contagious viral disease caused by RNA viruses that affects birds and mammals. Yearly vaccination would be the best way to prevent seasonal FLU.

CDC’s National Immunization Program (NIP) recommends the high risk persons to get immunized against Influenza if a person is in any of the following category:

1. Children aged 6 months up to their 19th birthday

2. Pregnant women

3. People 50 years of age and older

4. People of any age with certain chronic medical conditions

5. People who live in nursing homes and other long-term care facilities

6. People who live with or care for those at high risk for complications from flu, including:

i. Health care workers

ii. Household contacts of persons at high risk for complications from the flu

iii. Household contacts and caregivers of children less than 5 years of age with particular emphasis on vaccinating contacts of children less than 6 months of age (these children are at higher risk of flu-related complications.

To know more about vaccination and prevention of this infectious disease please click the link http://www.cdc.gov/flu/protect/preventing.htm


Coding guidelines for Influenza vaccine

The normal influenza vaccine contains three influenza viruses, Influenza A (H3N2) virus, one regular seasonal Influenza A (H1N1) virus (not the 2009 pandemic H1N1 virus) and Influenza B virus. No change in the CPT's to report a normal Influenza vaccine. Physicians can report Influenza vaccine and its administration using the same CPT codes as used earlier. CPT 90656 through CPT 90658 to report the vaccine itself and the administration of vaccine is reported using CPT G0008 if the claim is submitted to Medicare insurance. All the other insurance including Medicaid would accept CPT 90471 for vaccine administration.

CPT 90658 – Flu vaccine itself CPT G0008 - vaccine administration (Medicare) ICD V04.81
CPT 90658 – Flu vaccine itself CPT 90471 - vaccine administration (Commercials and Medicaid) ICD V04.81

ICD V04.81 denotes 'Need for prophylactic vaccination and inoculation, Influenza'.

The reimbursement for CPT G0008 and CPT 90471 would be the same. To check the annual update (2009-2010) on the reimbursement for vaccine codes, please click the link

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6608.pdf

The optimal time to get a flu vaccine is in October or November and Medicare reimburses health care providers under Part B for seasonal flu vaccines and its administration without any out-of-pocket costs to the Medicare patient. No deductible or copayment / coinsurance applied.

2009 H1N1 (Swine Flu) Outbreak

Due to 2009 swine flu outbreak CDC has recommended 2009 monovalent H1N1 influenza vaccine along with the seasonal Influenza vaccine for all Health care professionals and high risk patients. Physicians in order to report H1N1 vaccine and its administration they need to submit CPT 90663 (Influenza virus vaccine, pandemic formulation, H1N1) in conjunction with CPT 90470 (H1N1 immunization administration (intramuscular, intranasal), including counseling when performed). The reimbursement would be made only for the administration of vaccine and no separate reimbursement would be made for the vaccine.

CMS has created a set of new HCPCS Level II codes to report the H1N1 vaccine itself and the immunization administration. The new HCPCS codes are G9142 to report the vaccine itself and G9141 to report the administration including the physician counseling. As per CMS the reimbursement for CPT G9141 would be same as per the 2009 approved amount for CPT G0008 and no separate reimbursement made for CPT G9142.

Frequently Asked Questions on H1N1 vaccines

http://www.cms.hhs.gov/H1N1/Downloads/H1N1_Medicare_FFS_Emergency_QsAs.pdf

Important links

MLN updates on CPT G9141 and CPT G9142

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6617.pdf

American Medical Association updates on CPT 90663 and CPT 90470

http://www.ama-assn.org/ama/pub/h1n1/resources/cpt-codes.shtml

American Medical Association updates on H1N1 FAQs

http://www.ama-assn.org/ama1/pub/upload/mm/362/ama-fact-sheet-h1n1-reporting.pdf

Insurance updates on H1N1 vaccine codes and its reimbursement

Medicaid and CHIP
http://www.medicare.gov/Publications/Pubs/pdf/11440.pdf

Cigna reimbursement for H1N1 vaccination
http://www.cignagovernmentservices.com/partb/pubs/mb/2009/10_09/index.html#014

United Health Care Groups
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/H1N1/H1N1_letter_FAQ.pdf

Tricare Reimbursement for Routine Influenza vaccine
http://www.triwest.com/provider/newslist.aspx?aud=1&xf=102309_flushotClarification

Tricare Reimbursement for Influenza A (H1N1) Virus Vaccine
http://www.triwest.com/provider/newslist.aspx?aud=1&xf=102309_h1n1Clarification


Pneumococcal pneumonia - is an infection in the lungs caused by bacteria called Streptococcus pneumoniae. Vaccination is the only available method to prevent pneumococcal disease. 'World Pneumonia Day' is observed on November 2 to ensure that necessary intervention reaches children in the world’s most vulnerable countries.There are two different vaccines to prevent pneumococcal disease based on the age group. One is PCV, Pneumococcal conjugate vaccine for children up to 5 years of age and the other one is PPV23, Pneumococcal polysaccharide vaccine recommended for all those aged 65 years and older and for those between 2 and 64 years of age with certain long term medical conditions. The high risk persons are

1. All adults 65 years of age and older

2. All persons 2 years of age and older with

i. Chronic disease of the heart, lungs, liver or kidneys

ii. Anatomic or functional asplenia (without a spleen)

iii. Immunocompromised conditions (due to disease, cancer, chemotherapy, or steroids) includes Weakened immune system

iv. HIV infection.

Coding guidelines for Pneumococcal vaccine

Pneumococcal conjugate vaccine, PCV would be reported with CPT 90669 for the vaccine itself and CPT 90471 for administration of vaccine. Pneumococcal polysaccharide vaccine 23-valent, PPV23 would be reported with CPT 90732 and administration of the same is reported with CPT 90471. These codes are reimbursable by commercial insurance and Medicaid. Medicare reimburses CPT 90732 for PPV23 vaccine and the administration of vaccine would be reimbursed only if CPT G0009 is reported.

CPT 90732 - PPV23 vaccine CPT 90471 - vaccine administration (Commercial and Medicaid) ICD V03.82
CPT 90732 - PPV23 vaccine CPT G0009 - vaccine administration (Medicare) ICD V03.82

ICD V03.82 denotes 'Need for prophylactic vaccination against streptococcus pneumoniae (pneumococcus)'.

More infomation is available at http://www.cdc.gov/vaccines/vpd-vac/pneumo/default.htm

World Health Organization and Pneumococcal vaccines
http://www.who.int/vaccines/en/pneumococcus.shtml

How to report both Influenza and Pneuomococcal vaccination on the same day?

We could report both these vaccines using appropriate CPT's and ICD's.

CPT 90658 - Flu vaccine CPT 90471 - Flu Vaccine administration ICD V06.6
CPT 90732 - Pneumo vaccine CPT 90472 - Pneumo vaccine administration (additional) ICD V06.6

The above scenario applies for Medicaid and Commercial insurances. The appropriate CPT to report Medicare is as follows

CPT 90658 - Flu vaccine CPT G0008 - Flu Vaccine administration ICD V06.6
CPT 90732 - Pneumo vaccine CPT G0009 - Pneumo vaccine administration (additional) ICD V06.6

ICD V06.6 denotes 'Need for prophylactic vaccination with streptococcus pneumoniae (pneumococcus) and influenza'.

A quick reference guide to report vacccines
http://www.cms.hhs.gov/mlnproducts/downloads/qr_immun_bill.pdf

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