Reporting H1N1 Influenza Immunization Services Provided to Patients Covered Under Commercial Insurance—Updated September 7, 2009 (Online Exclusive)
October 2009
**Please check the AAP Pediatric Coding Newsletter News and Events for updates and changes regarding H1N1 reporting.** 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 (eg, 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. The majority 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 Immunization Administration Immunization administration should be reported using pediatric-specific Current Procedural Terminology (CPT®) codes 90465 or 90466 if the physician personally counsels the patient or family and so documents that he or she performed the counseling. | 90465 | Immunization administration younger than 8 years (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day | | 90466 | Immunization administration younger than 8 years (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure.) |
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If the physician does not personally perform and document face-to-face counseling, immunization administration is reported with codes 90471 or 90472 as appropriate. | 90471 | Immunization administration (includes percutaneous, intradermal, subcutaneous, and intramuscular); one vaccine (single or combination vaccine/toxoid) | | 90472 | Immunization administration (includes percutaneous, intradermal, subcutaneous, and intramuscular); each additional vaccine (single or combination vaccine/toxoid) |
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Coding the H1N1 Influenza Virus Vaccine According to the American Medical Association, CPT code 90663 (influenza virus vaccine, pandemic formulation) should be reported for the H1N1 influenza vaccine product until new and more specific codes can be developed. The reporting of the vaccine product itself (90663 or other new codes) is payer specific. Some payers are in the process of making a final policy for reporting services. Following are some of the options that you may need to follow when reporting administration of the H1N1 vaccine: Report immunization administration (codes 90465, 90466, 90471, or 90472) only. Update: National carriers Aetna, Health Net, Wellpoint, BlueCross BlueShied (BCBS) of Illinois, BCBS of Michigan, BCBS of Texas, Independence, and Highmark intend to pay for immunization administration of H1N1 based on their current rates for immunization administration codes 90465–90474. Report the vaccine product code (eg, 90663) with a "$0.01" charge and the immunization administration (90465, 90466, 90471, or 90472). Update: UnitedHealthcare requires reporting the services in this manner. Report the vaccine product (eg, 90663) without an associated fee (ie, field left blank) and with the immunization administration (90465, 90466, 90471, or 90472). Report the vaccine product (eg, 90663) with a charge and append Healthcare Common Procedure Coding System (HCPCS) modifier SL (state-supplied vaccine) or SE (state- or federally funded programs/services) in addition to the immunization administration (90465, 90466, 90471, or 90472). Medicare will require reporting administration of the H1N1 influenza virus vaccine with new HCPCS code G9141 (influenza A, H1N1, immunization administration). The payment will be the same as what it is currently under the program for administration of the seasonal influenza virus vaccine. Because some state Medicaid programs and commercial carriers follow Medicare policies, they may also require reporting with code G9141.
All services should be reported with International Classification of Diseases, Ninth Revision, Clinical Modification code V04.81 (need for prophylactic vaccination and inoculation against influenza). Reporting the H1N1 Vaccine and Seasonal Influenza Virus Vaccine (90655, 90656, 90657, 90658, and 90660) When Administered on the Same Day of Service Again, reporting will be payer specific. Some payers may require that code G0008 (administration of influenza virus vaccine) be reported instead of reporting each specific vaccine product. An immunization administration code should be additionally reported in association with each vaccine product administered. Reporting Services Provided to Patients Covered Under Vaccines for Children Program Services should be reported based on the policies mandated by the Medicaid program in your state. Check with your state program for the specific criteria for reporting 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. AAP members can access up-to-date information about coverage and billing requirements of major payers on the AAP Web site at www.aap.org/moc/reimburse/default.cfm. You can also research the policies of your major payers on their individual Web sites. |