UPDATED for 2016-2017 CRACKING THE CODES: CODING AND BILLING FOR VACCINATION WITH FLUZONE, INFLUENZA VACCINES Value transfers to licensed health care professionals by pharmaceutical companies may need to be reported according to certain state laws, as well as the federal Sunshine Act provisions. WEBINAR 1 CODING FOR FLUZONE VACCINATION COVERAGE, CODING, AND REIMBURSEMENT POLICIES VARY SIGNIFICANTLY BY INSURER, PLAN, AND PATIENT. INFORMATION PROVIDED DOES NOT GUARANTEE COVERAGE, PAYMENT, OR REIMBURSEMENT FROM ANY INSURER FOR PROCEDURES, SERVICES OR PRODUCTS. PROVIDER PARTICIPATION, PATIENT ELIGIBILITY, AND MEDICAL NECESSITY, AND APPLICABLE STATE AND FEDERAL REQUIREMENTS MAY BE USED BY INSURERS TO DETERMINE WHETHER REIMBURSEMENT WILL BE MADE WHEN A CLAIM IS RECEIVED. 1
AGENDA Coding for Fluzone vaccines Coding for administration Other coding considerations Case studies WHY INFLUENZA CODING IS SO IMPORTANT The Advisory Committee on Immunization Practices (ACIP) recommends all persons 6 months of age or older be vaccinated annually to help prevent influenza 1 There are many vaccines and coding variables Influenza Vaccine 25 20 CPT a Codes Codes 1,2 7 CPT Vaccine Administration 6 Codes Codes 1,2 HCPCS 5 b Codes HCPCS HCPCS 1 Code HCPCS a CPT (Current Procedural Terminology) is a registered trademark of the American Medical Association; b HCPCS = Healthcare Common Procedural Coding System. References: 1. Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), United States, 2015-2016 influenza season. MMWR. August 7, 2015/64(30);818-25. 2. American Academy of Pediatrics (AAP). Vaccines coding table. https://www.aap.org/en-us/professional-resources/practice-support/coding-at-the-aap/documents/vaccine%20coding%20table.pdf. Accessed April 5, 2016. 2
PROPER VACCINATION CODING Document all vaccinations in patient s medical record Bill for each vaccine and its administration 1 Vaccine Code Diagnosis Code Z23 Administration Code(s) Terms: We use the term vaccine to refer to the vaccine itself We use administration to refer to the act of giving the vaccine to a patient And we use vaccination to refer to the vaccine and its administration as one Always keep staff aware of which vaccine is used Reference: 1. AAP. Vaccines coding table. https://www.aap.org/en-us/professional-resources/practice-support/coding-at-the-aap/documents/vaccine%20coding%20table.pdf. Accessed April 5, 2016. INFLUENZA VACCINE CODE DISTINCTIONS AND TERMS 1,2 Route of Administration Intramuscular Intranasal Intradermal High-Dose by Content Enhanced immunogenicity via increased antigen content Preservative Content Preservative-free Adjuvant Added Adjuvanted Base Derived from cell cultures (cc) or recombinant DNA, hemagglutinin (HA) protein only (RIV) Split virus (IIV) a 6-35 months of age 0.25 ml dosage Virus Live (LAIV) b Subunit (IIV) Number of Antigens Trivalent (IIV3), (LAIV3), (cciiv3), (RIV3) Dosage 3 years of age and older 0.50 ml dosage Quadrivalent (IIV4), (LAIV4) a IIV = inactivated influenza vaccine; b LAIV = live attenuated influenza vaccine. Reference: 1. American Medical Association (AMA). CPT 2016 Standard Edition (Current Procedural Terminology [Standard]). Chicago, IL: American Medical Association; 2016. 2. AMA. CPT Assistant. Coding update for influenza vaccines. May 2016/ Volume 26 Issue 5. 3
CODING FOR FLUZONE HIGH-DOSE VACCINE Vaccine Age Indication 1 Presentation 1 2016-2017 11-Digit NDC a Package 2016-2017 11-Digit NDC CPT Unit Dose 1 Code Fluzone High-Dose vaccine 65 years and older 0.5-mL single-dose syringe 49281-0399-65 49281-0399-88 0.50 ml 90662 High-Dose Code 2 90662 Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use a NDC = National Drug Code. References: 1. Fluzone High-Dose Influenza Vaccine [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2015. 2. AMA. CPT 2016 Standard Edition (Current Procedural Terminology [Standard]). Chicago, IL: American Medical Association; 2016. CODING FOR FLUZONE INTRADERMAL QUADRIVALENT VACCINE Vaccine Fluzone Intradermal Quadrivalent vaccine Age Indication 1 Presentation 1 18-64 years 0.1-mL single-dose microinjection 2016-2017 11-digit NDC Package 2016-2017 11-digit NDC CPT Unit Dose 1 Code 49281-0710-40 49281-0710-48 0.1 ml 90630 Quadrivalent Intradermal Code 2 90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Trivalent Intradermal Code 2 90654 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, for intradermal use References: 1. Fluzone Intradermal Quadrivalent Influenza Vaccine [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2015. 2. AMA. CPT 2016 Standard Edition (Current Procedural Terminology [Standard]). Chicago, IL: American Medical Association; 2016. 4
CODING FOR FLUZONE QUADRIVALENT VACCINE, CONTAINS NO PRESERVATIVE Vaccine Fluzone Quadrivalent vaccine (Pediatric Dose): Contains no preservative Age Indication 1 Presentation 1 6-35 months 0.25-mL single-dose syringe 2016-2017 11-Digit NDC Package 2016-2017 11-Digit NDC CPT Unit Dose 1 Code 49281-0516-25 49281-0516-00 0.25 ml 90685 Fluzone Quadrivalent vaccine: Contains no preservative 3 years and older 0.50-mL single-dose syringe 49281-0416-50 49281-0416-88 0.50 ml 90686 Fluzone Quadrivalent vaccine: Contains no preservative 3 years and older 0.50-mL single-dose vial 49281-0416-10 49281-0416-58 0.50 ml 90686 Preservative-free Inactivated Quadrivalent Intramuscular Codes 2 90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to children 6-35 months of age 0.25 ml dosage, for intramuscular use 90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older 0.05 ml dosage, for intramuscular use References: 1. Fluzone Quadrivalent Influenza Vaccine [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2015. 2. AMA. CPT Assistant. Coding update for influenza vaccines. May 2016/ Volume 26 Issue 5. CODING FOR FLUZONE QUADRIVALENT VACCINE Vaccine Fluzone Quadrivalent vaccine Age Indication 1 Presentation 1 6 months and older 5-mL multidose vial 2016-2017 11-Digit NDC Package 49281-0625-15 49281-0625-78 2016-2017 11-Digit NDC Unit Dose 1 CPT Code 0.25 ml 90687 0.50 ml 90688 Inactivated Quadrivalent Intramuscular Codes 2 90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6-35 months of age 0.25 ml dosage, for intramuscular use 90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to individuals 3 years of age and older 0.5 ml dosage, for intramuscular use References: 1. Fluzone Quadrivalent Influenza Vaccine [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.; 2015. 2. AMA. CPT Assistant. Coding update for influenza vaccines. May 2016/ Volume 26 Issue 5. 5
TRIVALENT CODES NO LONGER APPLY FOR FLUZONE VACCINE 90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to children 6-35 months of age 0.25 ml dosage, for intramuscular use 90657 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6-35 months of age 0.25 ml dosage, for intramuscular use Inactivated Trivalent Intramuscular Codes 1 90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to individuals 3 years of age and older 0.5 ml dosage, for intramuscular use 90658 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to individuals 3 years of age and older 0.5 ml dosage, for intramuscular use Medicare Required Inactivated Trivalent Intramuscular HCPCS Code 2 Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Fluzone ) References: 1. AMA. CPT Assistant. Coding update for influenza vaccines. May 2016/ Volume 26 Issue 5. 2. Centers for Medicare & Medicaid Services (CMS). 2012-2013 Immunizers Question & Answer Guide to Medicare Part B, Medicaid and CHIP coverage of seasonal influenza and pneumococcal vaccinations: Steps to promoting wellness immunizations. http://www.cms.gov/medicare/prevention/immunizations/downloads/2012-2013_flu_guide.pdf. Accessed April 5, 2016. DECISION TREE FOR FLUZONE CODE SELECTION 2016-2017 High Dose? No Intradermal? No Fluzone High-Dose vaccine Standard Dose? Fluzone Intradermal Quadrivalent vaccine 90662 90630 Intramuscular? Preservative-free? Fluzone Quadrivalent vaccine (Pediatric Dose): Contains no preservative 90685 No No Fluzone Quadrivalent vaccine: Contains no preservative 90686 Preservativecontaining? [multidose vial] Fluzone Quadrivalent vaccine [0.25-mL dose from 5-mL vial] No 90687 Fluzone Quadrivalent vaccine [0.50-mL dose from 5-mL vial] 90688 6
CODING FOR ADMINISTRATION OF FLUZONE VACCINE FLUZONE VACCINE ADMINISTRATION BY-COMPONENT CODES 1 90460 AND 90461 CPT Code 90460 Code Type Primary per Component Description 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 Bill a unit for the first or only component within EACH vaccine Bill 1 unit for administering Fluzone vaccine +90461 Add-on per Component Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) A component is defined as protecting against one disease 1 Bill a unit for each additional component within a multicomponent vaccine Not applicable for Fluzone vaccine Influenza vaccine contains multiple strains but it is a single-component vaccine, protecting from only influenza virus 1 Reference: 1. AAP. Frequently asked questions for the pediatric immunization administration codes. https://www.aap.org/en-us/documents/coding_faq_immunization_ administration.pdf. Accessed April 5, 2016. 7
FLUZONE VACCINE ADMINISTRATION BY-COMPONENT CODES 90460 AND 90461 Billed By-Component Requisites Age Dependent Face-to-Face Counseling Qualified Health Care Professional (QHCP) Patient must be: 18 years of age and younger Includes things like: Providing the Vaccine Information Sheet (VIS) Discussing the pros and cons of vaccination and patient-specific issues At-home management of adverse reactions Answering patient and/or parent questions Per CPT Guidelines: Limited to individuals who are qualified by education, training, licensure/regulation, and facility privileging (when applicable), and who perform within their scope of practice and independently report professional services Documentation that counseling was provided by a QHCP and that the vaccine was administered References: 1. AAP. Frequently asked questions for the pediatric immunization administration codes. https://www.aap.org/en-us/documents/coding_faq_immunization_ administration. pdf. Accessed April 5, 2016. 2. AAP. Is the work of vaccine counseling included in the preventive medicine services codes? https://www.aap.org/en-us/professionalresources/practice-support/financing-and-payment/pages/is-the-work-of-vaccine-counseling-included-in-the-preventive-medicine-services-codes.aspx. Accessed April 5, 2016. FLUZONE VACCINE ADMINISTRATION BY-COMPONENT CODES 1 90460 AND 90461 Fluzone vaccine Influenza 90460 Tdap a Tetanus Diphtheria Pertussis 90460 90461 90461 CPT Code Code Type Description 90460 Primary per Component 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 Add-on per Component Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) a Tdap = Tetanus, diphtheria, and acellular pertussis. 8
FLUZONE VACCINE ADMINISTRATION BY-INJECTION CODES 1 90471 AND 90472 CPT Code Code Type 90471 Primary per Injection +90472 Add-on per Injection Description Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Bill a unit if Fluzone vaccine is the first or only vaccine administered at the encounter Bill a unit if Fluzone vaccine is administered after another vaccine at the encounter Billed by Route of Administration First or Additional Injection? Reference: 1. AMA. CPT 2016 Standard Edition (Current Procedural Terminology [Standard]). Chicago, IL: American Medical Association; 2016. FLUZONE VACCINE ADMINISTRATION BY-INJECTION CODES 1 90471 AND 90472 By-injection CPT codes, 90471 and 90472, are used when: Patients are 19 years of age or older OR Patients are younger than 19 years of age but counseling was not performed, was performed and not documented, or was performed by a health care professional who is not approved to bill for counseling per CPT Guidelines These codes are not component-based Coded as one unit for each vaccine administered, no matter how many components in the vaccine Reference: 1. AAP. Frequently asked questions for the pediatric immunization administration codes. https://www.aap.org/en-us/documents/coding_faq_immunization_ administration.pdf. Accessed April 5, 2016. 9
INFLUENZA VACCINE ADMINISTRATION VACCINE-SPECIFIC HCPCS CODE 1 G0008 HCPCS Code Code Type Description G0008 Medicare Administration of influenza virus vaccine Required When Billing Medicare for Administration of Any Influenza Vaccine Medicare does not recognize the previously discussed by-component or byinjection codes if the vaccine is influenza 1 This is true regardless of the patient s age or which influenza vaccine was administered Reference: 1. CMS. 2012-2013 Immunizers Question & Answer Guide to Medicare Part B, Medicaid and CHIP coverage of seasonal influenza and pneumococcal vaccinations: Steps to promoting wellness immunizations. http://www.cms.gov/medicare/prevention/immunizations/downloads/2012-2013_flu_guide.pdf. Accessed April 5, 2016. DECISION TREE FOR FLUZONE VACCINE ADMINISTRATION CODE SELECTION 1-3 Medicare patient? G0008 No Is patient 18 years of age? Was counseling by qualified HCP a provided and documented? No No Injectable vaccine? First vaccine today? No 90460 90471 +90472 a HCP = Health care provider. References: 1. CMS. 2012-2013 Immunizers Question & Answer Guide to Medicare Part B, Medicaid and CHIP coverage of seasonal influenza and pneumococcal vaccinations: Steps to promoting wellness immunizations. http://www.cms.gov/medicare/prevention/immunizations/downloads/2012-2013_flu_guide.pdf. Accessed April 5, 2016. 2. AAP. Frequently asked questions for the pediatric immunization administration codes. https://www.aap.org/en-us/documents/coding_faq_immunization_administration.pdf. Accessed April 5, 2016. 3. AMA. CPT 2016 Standard Edition (Current Procedural Terminology [Standard]). Chicago, IL: American Medical Association; 2016. 10
OTHER CODING CONSIDERATIONS INFLUENZA VACCINE DIAGNOSIS CODE ICD-10 a Code Description Suggested Use Z23 Encounter for immunization 1 immunizations and immunization Primary diagnosis code used for all routine administration Modifier -SK linked to the vaccine code also identifies a patient as high risk 2 a ICD-10 = International Classification of Diseases, Tenth Revision. References: 1. CDC. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). http://www.cdc.gov/nchs/icd/icd10cm.htm. Accessed April 5, 2016. 2. California Medical Assistance. Immunizations. https://view.officeapps.live.com/op/view.aspx?src=http%3a%2f%2ffiles.medi-cal.ca.gov%2fpubsdoco%2fpublications %2FMasters-MTP%2FPart2%2Fimmun_m00o03o04o11p00.doc. Accessed April 5, 2016. 11
ICD-10 VACCINATION CODES ICD-10 Code 1 Description Range of Codes When to Use Z23 Encounter for immunization Z23 Use for routine vaccinations Z20 Contact with and (suspected) exposure to communicable diseases Z20.0 Z20.9 Use when the patient has been exposed to a communicable disease Z22 Carrier of infectious disease Z22.0 Z22.9 Use when the patient is a carrier or suspected carrier of an infectious disease Z28 Immunization not carried out and under immunization status Z28.0 Z28.9 Use when the patient is under-immunized, too ill for vaccination, or refuses vaccination See our Resource section at www.crackingthecodestraining.com/resources for a list of all vaccination ICD-10 codes Reference: 1. CDC. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). http://www.cdc.gov/nchs/icd/icd10cm.htm. Accessed April 5, 2016. REPORTING REVENUE CODES FOR INFLUENZA VACCINATION 1 Facility Providers Also Add Revenue Codes to Claims Vaccine Revenue Code 0636 Pharmacy, Drugs Requiring Detailed Coding Vaccine Administration Revenue Code 0771 Preventive Care Services, Vaccine Administration Reference: 1. CMS. 2012-2013 Immunizers Question & Answer Guide to Medicare Part B, Medicaid and CHIP coverage of seasonal influenza and pneumococcal vaccinations: Steps to promoting wellness immunizations. http://www.cms.gov/medicare/prevention/immunizations/downloads/2012-2013_flu_guide.pdf. Accessed April 5, 2016. 12
REPORTING NATIONAL DRUG CODES (NDC) Some payers may require you to include the vaccine s NDC number on the claim Food and Drug Administration (FDA) guidelines now require all manufacturers to assign different NDCs to a product s outer carton (unit of sale) and the vial or syringe (unit of use) Check with your payers to see which NDC they prefer, or if they accept either The common format for submitting an NDC is a number that, if hyphenated, would appear in a 5-4-2 format. Some drug products are labeled in 4-4-2, 5-3-2, or 5-4-1 formats 1 To change these codes to the 11-digit format, a zero is placed within the product code to create the 5-4-2 format 1 10-Digit NDC 11-Digit NDC 4444-4444-22 04444-4444-22 55555-333-22 55555-0333-22 55555-4444-1 55555-4444-01 Keep in mind that this information is not required by all payers 1 Reference: 1. American Academy of Family Physicians (AAFP). Coding for vaccine administration http://www.aafp.org/practice-management/payment/coding/ admin.html. Accessed May 2, 2016. CODING OFFICE VISITS WITH VACCINATION SERVICES Payers who follow the national Correct Coding Initiative (CCI) effective 1/1/13 require modifier -25 when vaccine administration and a separate and significant E/M a service are performed at the same visit Applies to sick and well visits Modifier -25 is attached to the E/M service Modifier -25 is not added to the vaccine administration code The administration code trumps the E/M code If you bill a vaccine administration code and an E/M code for the same patient on the same date and do not append modifier -25 to the E/M code, Medicare, Medicaid and other payers who follow the CCI edits will only pay for the vaccine administration CCI will not allow the addition of a modifier to report both 99211 and a vaccine administration a E/M = Evaluation and management. References: 1. CMS. Medicare Claims Processing Manual. Chapter 18 Preventive and Screening Services. (Rev. 2575, 10-26-12.) http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/clm104c18.pdf. Accessed April 5, 2016. 2. CMS. 2012-2013 Immunizers Question & Answer Guide to Medicare Part B, Medicaid and CHIP coverage of seasonal influenza and pneumococcal vaccinations: Steps to promoting wellness immunizations. http://www.cms.gov/medicare/prevention/immunizations/ Downloads/2012-2013_Flu_Guide.pdf. Accessed April 5, 2016. 13
CASE STUDIES CASE STUDY FLUZONE QUADRIVALENT VACCINE (PEDIATRIC DOSE): CONTAINS NO PRESERVATIVE Scenario: A 7-month-old patient with private insurance is seen for an evaluation and receives Fluzone Quadrivalent vaccine (Pediatric Dose): Contains no preservative. This is the first time the child is immunized against influenza. The physician assistant counsels the child s parent on the vaccine. A 30-day follow-up appointment is scheduled for the child to receive a second dose of vaccine. First Dose DOS 9/15/16 Code Modifier Description ICD-10 Code 99213-25 a Outpatient visit L22 90685 Influenza vaccine, IIV4, preservative-free, 0.25-mL dosage, IM Z23 90460 Vaccine administration with qualified counseling 18 years of age, first component Coding for Administration of Fluzone Quadrivalent Vaccine (Pediatric Dose): Contains No Preservative [CPT 90685] Z23 [CPT 90685] 90460 90461 90471 90472 G0008 Use with CPT 90685 when patient is 6-35 months of age and qualified counseling is provided and documented N/A Use with 90685 when patient is 6-35 months of age and qualified counseling is not provided or documented: if this is the first vaccine administered at the encounter Use with 90685 when patient is 6-35 months of age and qualified counseling is not provided or documented: if this is administered after another vaccine at the encounter Use with 90685 if patient is covered by Medicare a Modifier -25 is attached to identify that separate and significant services were provided at the visit. The patient was not there just to receive the vaccine. 14
CASE STUDY FLUZONE QUADRIVALENT VACCINE (PEDIATRIC DOSE): CONTAINS NO PRESERVATIVE SECOND DOSE [CPT 90685] Scenario: The same 7-month-old patient with private insurance returns for a second dose of Fluzone Quadrivalent vaccine (Pediatric Dose): Contains no preservative. The registered nurse counsels the child s parent on the vaccine. No other billable services are provided when the child receives the second dose. Second Dose DOS 10/16/16 Code Description ICD-10 Code 90685 Influenza vaccine, IIV4, preservative-free, 0.25-mL dosage, IM Z23 90471 Vaccine administration, first injection Z23 Coding for Administration of Fluzone Quadrivalent Vaccine (Pediatric Dose): Contains No Preservative [CPT 90685] 90460 90461 90471 90472 G0008 Use with CPT 90685 when patient is 6-35 months of age and qualified counseling is provided and documented N/A Use with 90685 when patient is 6-35 months of age and qualified counseling is not provided or documented: if this is the first vaccine administered at the encounter Use with 90685 when patient is 6-35 months of age and qualified counseling is not provided or documented: if this is administered after another vaccine at the encounter Use with 90685 if patient is covered by Medicare Reference: 1. CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), United States, 2015-2016 influenza season. MMWR. August 7, 2015/64(30);818-25. CASE STUDY FLUZONE QUADRIVALENT VACCINE: CONTAINS NO PRESERVATIVE [CPT 90686] Scenario: A 14-year-old patient with private insurance is seen at the physician s office for a well visit. The physician recommends and counsels on why she should receive and administers Fluzone Quadrivalent vaccine: Contains no preservative, a tetanus, diphtheria, acellular pertussis (Tdap) vaccine, and a meningococcal ACWY vaccine. Code Modifier Description ICD-10 Code 99384-25 Well visit Z00.3 90686 Influenza vaccine, IIV4, preservative-free, 0.5-mL dosage, IM Z23 90715 Tdap vaccine Z23 90734 MenACWY vaccine Z23 90460 x 3 Vaccine administration, first or only component (influenza, tetanus, meningococcal) Z23 90461 x 2 Vaccine administration, each additional component (diphtheria & pertussis) Z23 Coding for Administration of Fluzone Quadrivalent Vaccine: Contains No Preservative [CPT 90686] 90460 90461 90471 90472 G0008 Use with CPT 90686 when patient is 3-18 years of age and qualified counseling is provided and documented N/A Use with 90686 when patient is 19 years of age and older or when the patient is 3-18 years of age and qualified counseling is not provided or documented: if this is the first vaccine administered at the encounter Use with 90686 when patient is 19 years of age and older or when the patient is 3-18 years of age and qualified counseling is not provided or documented: if this is administered after another vaccine at the encounter Use with 90686 if patient is covered by Medicare 15
CASE STUDY FLUZONE INTRADERMAL QUADRIVALENT VACCINE [CPT 90630] Scenario: A 34-year-old patient with private insurance is seen in the physician s office for knee pain. The physician recommends, counsels on and administers a dose of Fluzone Intradermal Quadrivalent vaccine. Code Modifier Description ICD-10 Code 99213-25 Office visit M25.561 90630 Influenza vaccine, IIV4, preservative-free, intradermal injection Z23 90471 Vaccine administration, first injection Z23 Coding for Administration of Fluzone Intradermal Quadrivalent Vaccine [CPT 90630] 90460 90461 90471 90472 G0008 Use with CPT 90630 when patient is 18 years of age and qualified counseling is provided and documented N/A Use with 90630 when patient is 19 years of age and older or when the patient is 18 years of age and qualified counseling is not provided or documented: if this is the first vaccine administered at the encounter Use with 90630 when patient is 19 years of age and older or when the patient is 18 years of age and qualified counseling is not provided or documented: if this is administered after another vaccine at the encounter Use with 90630 if patient is covered by Medicare CASE STUDY FLUZONE HIGH-DOSE VACCINE [CPT 90662] A 72-year-old Medicare beneficiary is seen at the physician s office for an annual well visit. The physician takes the opportunity to immunize the patient against influenza using Fluzone High-Dose vaccine. Code Modifier Description ICD-10 Code G0439-25 Annual well visit Z00.00 90662 Influenza vaccine, IIV, increased antigen content, IM Z23 G0008 Administration of influenza vaccine Z23 Coding for Administration of Fluzone High-Dose Vaccine [CPT 90662] 90460 90461 90471 90472 G0008 N/A N/A Use with 90662 if this is the first vaccine administered at the encounter Use with 90662 if this is administered after another vaccine at the encounter Use with 90662 if patient is covered by Medicare 16
CASE STUDY FLUZONE QUADRIVALENT VACCINE [CPT 90688] A 62-year-old Medicare patient is seen at an immunization clinic and receives a 0.5-mL dose of Fluzone Quadrivalent vaccine taken from a 5-mL vial. Code Description ICD-10 Code 90688 Influenza vaccine, IIV4, 0.5-mL dosage, IM Z23 G0008 Administration of influenza vaccine Z23 Control Number for Contractor Use Only. L e a v e b l a n k Health Insurance Claim Number Patient Last Name Consider Roster Billing 1 Patient First Name EnFlewEnssus Clinic 555 Respiratory Rd, Sickster MO NPI: 00XXX00 Date of Service: 10/01/16 Patient Middle Initial 511-xx-1111A Brown June R. 522-xx-1222B Green May C. 533-xx-1333A Moon Sonny A. Patient Address & Zip Code Date of Birth Gender 21 Main St. Anytown, MO 01225 405 Missouri Ave. Sickster, MO 01121 5 Spring St. Sickster, MO 01121 Patient Signature 3/17/1932 F On file 2/14/1946 F On file 12/25/1929 M On file Reference: 1. CMS. 2012-2013 Immunizers Question & Answer Guide to Medicare Part B, Medicaid and CHIP coverage of seasonal influenza and pneumococcal vaccinations: Steps to promoting wellness immunizations. http://www.cms.gov/medicare/prevention/immunizations/downloads/2012-2013_flu_guide.pdf. Accessed April 5, 2016. PLAN OF ACTION FOR YOUR PRACTICE OR FACILITY Be sure you are coding correctly for the vaccine you are administering Update your superbill and encounter forms Be sure you have updated your charges to cover the cost of the current season s vaccine Educate your office leadership and staff Investigate your major payer and Medicaid policies on billing procedures Monitor your explanation of benefits (EOB) Aggressively define and pursue related issues Consult resources 17
BE SURE TO VIEW WEBINAR 2 AND RESOURCES Webinar 2: Medicaid and Medicare Billing for Influenza Vaccination Medicaid modified billing rules for publicly-supplied and privately-purchased vaccine Medicaid payment Medicare billing rules and payment Downloadable Resources available at http://www.crackingthecodestraining.com/resources ICD-10 and vaccines State-specific Medicaid coding and billing information Detailed roster billing instructions Links to resources QUESTION-AND-ANSWER PERIOD Be sure to also view Webinar 2 Medicaid and Medicare and Influenza Vaccine http://www.crackingthecodestraining.com 18
THANK YOU FOR PARTICIPATING IN THIS WEBINAR SANOFI PASTEUR. Discovery Drive. Swiftwater, Pennsylvania 18370. www.sanofipasteur.us MKT30928 2016 Sanofi Pasteur Inc. 7/16 19