- Copyright © 2009 by the American Academy of Pediatrics
Vaccine coding: Seasonal and H1N1 influenza
Using Current Procedural Terminology (CPT) Level I codes, report one of the appropriate seasonal flu vaccine codes:
90655 — Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use;
90656 — Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use;
90657 — Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use;
90658 — Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use; or
90660 — Influenza virus vaccine, live, for intranasal use.
In addition, report one of the appropriate immunization administration (IA) codes:
90465 — IA younger than 8 years of age when the physician counsels the patient/family; first injection, per day
90466 — IA younger than 8 years of age when the physician counsels the patient/family; each additional injection, per day
90467 — IA younger than 8 years of age (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration
90468 — IA younger than 8 years of age (includes intranasal or oral routes of administration) when the physician counsels the patient/family; each additional administration, per day
90471 — IA (includes percutaneous, intradermal, subcutaneous or intramuscular); first injection
90472 — IA (includes percutaneous, intradermal, subcutaneous or intramuscular); each additional injection
90473 — IA by intranasal or oral route; first vaccine
90474 — IA by intranasal or oral route; each additional vaccine
Report the following CPT codes for the H1N1 vaccine serum:
90663 — Influenza virus vaccine, pandemic formulation
90470* — H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
*Code 90470 became effective Sept. 28, 2009.
An alternative code set for H1N1 immunization has been developed and released by the Centers for Medicare & Medicaid Services. These codes are Medicare’s National Level II Codes or more commonly referred to as the Healthcare Common Procedure Coding System (See New CPT codes, page 15). Some third-party payers are requiring these codes instead of the CPT codes to report the H1N1 vaccine serum and administration.
G9141 — Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
G9142 — Influenza A (H1N1) vaccine, any route of administration
National Drug Code (NDC)
To meet the needs of the Centers for Disease Control and Prevention (CDC) safety monitoring programs, it is highly suggested to list the NDC assigned by the Food and Drug Administration (www.accessdata.fda.gov/scripts/cder/ndc/default.cfm) on the claim form in addition to 90663 or G9142 (see National Uniform Claim Committee NUCCT 1500 Claim Form Instruction Manual, pages 43-45, www.nucc.org/images/stories/PDF/claim_form_manual_v5-0_7-09.pdf).
For more information on NDC numbers, log onto the AAP Member Center and go to www.aap.org/moc/reimburse/ndc.html.
Report International Classification of Diseases, 9th Revision — Clinical Modification (ICD-9-CM) code V04.81 (need for prophylactic vaccination and inoculation, influenza) for both the seasonal influenza vaccine and the H1N1 vaccine. You also may consider adding ICD-9-CM code V07.8 for patients whom you vaccinate, due to their contact with high-risk patients.
Other H1N1 related ICD-9-CM codes are as follows:
488.1 Influenza due to identified novel H1N1 influenza virus
V87.39 Contact with and (suspected) exposure to other potentially hazardous substances
Following is an example of how to report CPT and ICD-9-CM codes:
A 2-year-old patient receives her seasonal influenza vaccine along with an H1N1 vaccine after the physician counsels the mom on both. The seasonal influenza vaccine is a preservative-free injection.
Report codes 90655, 90465, 90663, 90470, and link all four CPT codes with ICD-9 code V04.81.
It is important to check with your payers to determine coverage and eligibility. If the H1N1 vaccine is a covered benefit and you are contracted with a patient’s insurance payer, then you are required to bill that payer for the service.
While most carriers have determined that they will cover and pay for the H1N1 vaccine, it is important to check with your individual payers regarding their reporting policies for the H1N1 vaccine as they may vary. It also is important to ask the parents or guardians to sign a waiver notice, which states that the responsible party (patient/parent/legal guardian) accepts financial responsibility for a requested medical service which is not or may not be covered by health insurance.
Rapid influenza testing
Many pediatric practices perform rapid influenza testing in their office. With the concern over H1N1 influenza, many practices are using the rapid influenza tests that can determine if the patient is positive for influenza A or influenza B.
If you are running a rapid influenza test in your office that can provide you results for the two distinct strains of the virus (e.g., patient is positive for influenza A but negative for influenza B), report the appropriate CPT code for the rapid influenza test twice, or with two units depending on the payer. CPT instructs to report code 87804 and 87804 appending the 59 modifier to indicate that two distinct rapid influenza tests were performed.
For the most current information on the H1N1 virus, visit the Centers for Disease Control and Prevention (CDC) Web site:
H1N1 Flu home page: www.cdc.gov/h1n1flu/
H1N1 Flu Clinical and Public Health Guidance: www.cdc.gov/h1n1flu/guidance/
Interim Recommendations for Clinical Use of Influenza Diagnostic Testing During the 2009-2010 Influenza Season: www.cdc.gov/h1n1flu/diagnostic_testing_clinicians_qa.htm
Updated coding information also is available on the AAP Member Center: www.aap.org/moc/reimburse/codingrbrvsresources.htm (log-in required).