How to code, bill for H1N1 flu vaccine

Vaccines that provide protection against influenza A(H1N1) are being provided free by the Centers for Disease Control and Prevention, and new Current Procedural Terminology codes have been issued to cover physicians' costs of delivering the service. Insurers, however, have subtle differences in how they want billing handled.

"This is a fairly unique situation, and there will be some confusion," said Warren Brandle, MD, a family physician in Gold River, Calif. "But [getting the vaccines] costs the physician nothing. There is no risk for the physician, and we will be protecting our community from a worsening of what we are already seeing. We are seeing cases [of H1N1] every day in our office."

Various CPT codes already exist for administering vaccines, including those given in a pandemic, but physicians are being asked to use new codes developed specifically for administering H1N1 vaccines.

According to a statement issued by the American Medical Association Sept. 28, newly developed CPT code 90470 should be used to cover the administration and counseling for either the intramuscular or intranasal version of the H1N1 vaccine. CPT code 90663 also was revised to include the H1N1 immunization and should be used for the vaccine itself.

The AMA expedited the development of CPT codes specific to H1N1 in response to a request from the Dept. of Health and Human Services to streamline reimbursement procedures and aid tracking of the vaccine. The immunization, along with related medical supplies, is being provided at no cost, which means physicians will be paid only for administration and counseling. Some insurers are asking physicians to code only for that.

But other insurers are asking physicians to code for the vaccine, with a billing amount of either zero dollars or one cent. The one cent amount can also be used if a physician's billing software won't recognize a zero dollar amount.

"They need to code for it, but there may be some software problems," said Janalynne Thorley-Kilgo, an education specialist with the American Academy of Professional Coders. "Physicians need to check with their software vendors."

Complicating the situation further, some insurers will accept the more generic vaccine administration codes, although the specific ones are preferred. But there could be variances by insurer over pay. For example, administration of the intranasal vaccine is sometimes reimbursed at a lower rate than administration of the intramuscular version.

Several insurers also have announced that patients will not be subject to co-pays or coinsurance for the H1N1 vaccine, even if vaccine coverage is not usually included in their plan. Coding correctly in that situation is even more important.

"We are providing first-dollar coverage. That means we are waiving all co-pays, coinsurance and deductibles for all our fully insured health plan members. For self-funded members, we are doing this unless directed otherwise," said Bill Fried, MD, the national lead for H1N1 preparedness at Aetna. "We are part of the national effort to respond to H1N1, which is a national emergency. We want to be responsive not only to the national needs but also to our members' needs."

Here are examples of how some insurers are handling the situation:

Medicare: HCPCS G9141 should be used for the administration. HCPCS G9142 can be used for the vaccine.

Cigna: Either the CPT code 90470 or the HCPCS G9141 should be used for administration. This can be accompanied by vaccine codes 90663 or G9142.

Aetna: Either the CPT code 90470 or the HCPCS G9141 should be used for administration. Coding for the vaccine is unnecessary.

Priority Health: CPT code 90470 or HCPCS G9141 should be used for the administration, although any of the relevant vaccine codes will be accepted.

Experts advise contacting individual insurers to determine how claims will be processed.

The H1N1 codes can be used alone if patients are coming in only for the H1N1 vaccine or can be combined with other codes if patients are there for other services, such as the seasonal influenza vaccine or care for a chronic condition.

The CDC's National Center for Health Statistics also issued new ICD-9 codes effective Oct. 1. The number 488.0 should be used for influenza due to identified avian influenza virus, and 488.1 is the one for influenza due to identified novel H1N1 influenza virus.