- Copyright © 2009 by the American Academy of Pediatrics
As preparations are under way for the novel influenza A H1N1 (swine flu) vaccine, a critical component is determining how vaccine administration will be reported and paid.
The federal government has said that the vaccine will be provided at no cost to health care professionals. However, physicians still need to be paid for immunization administration.
The Academy’s private payer advocacy area contacted the 12 largest national and regional private pay carriers regarding their plans for coverage of and payment for the administration of the H1N1 influenza vaccine.
Representatives from Aetna, Blue Cross Blue Shield (BCBS) of Illinois, BCBS of Michigan, Health Net, Highmark Blue Cross, Independence Blue Cross, UnitedHealthcare (UHC) and WellPoint indicated that their systems would pay for immunization administration for members whose benefit plans provide coverage for vaccines.
Additionally, UHC will provide coverage for the administration of the H1N1 influenza vaccine for all members covered by its insured plans and intends to process all self-funded member claims as a covered service.
By taking action now, the Academy compelled the national carriers to review their claims processing systems procedures related to the H1N1 influenza vaccine. Some carriers were unclear of which code to use or how to process claims in which the vaccine is provided at no charge.
At press time, there was not yet a Food and Drug Administration-approved H1N1 influenza vaccine or a CPT code specific to the H1N1 influenza vaccine. In the interim, the American Medical Association (AMA) indicates that CPT code 90663 (influenza virus vaccine, pandemic formulation) be reported for the H1N1 influenza vaccine. While this code was created for circumstances in which a pandemic influenza virus occurs, the AMA will be working with the Centers for Disease Control and Prevention to develop a new vaccine code specific to H1N1 influenza.
Should the H1N1 influenza vaccine be provided at no cost to the physician, modifier SL (state supplied vaccine) would be appended to CPT code 90663. This would cue the claims system that the vaccine was provided at no cost, and the system would not expect a corresponding charge for the vaccine.
The Academy will provide members and payers with updated information on coding and billing for the H1N1 influenza vaccine on the AAP Member Center, www.aap.org/moc.