Fam Pract Manag. 2009 Nov-Dec;16(6):30.
How should we code and bill for the H1N1 vaccine and its administration?
Most privately insured patients will have benefits for the H1N1 vaccine administration even if their health plan does not typically cover preventive services; this is due to collaboration between the U.S. Department of Health and Human Services and payers.
Medicare allows physicians to provide and bill for both H1N1 and seasonal influenza vaccines on the same date. Medicare created a new G code for administration of the H1N1 vaccine; submit code G9141 with diagnosis code V04.81. It is not necessary to report a separate code for the vaccine itself, but if you prefer to include it in your documentation, use code G9142. If billed, this code will be denied since the vaccine is provided at no cost.
For the standard seasonal influenza vaccine and administration, use codes G0008 for the administration, V04.81 for the diagnosis, and the appropriate CPT code for the vaccine itself (i.e., 90655, 90656, 90657, 90658 or 90660).
Medicare will not pay for an office visit if the sole purpose of the visit is vaccine administration but will if a significant, separately identifiable E/M service is provided on the same date.
In late September, the AMA's CPT Editorial Panel created a new code, 90470, for H1N1 vaccine administration. Several national payers have indicated that they will accept either this code or HCPCS code G9141. Check with your local payers to determine what to do when billing for privately insured patients.
H1N1 sick visits
What diagnosis codes should I use for visits with patients who are sick with H1N1 or seasonal flu? How should in-office tests be reported?
Code 488.1 is specific to influenza due to the H1N1 virus. Code 487.1 is still valid for patients with influenza not otherwise specified and other respiratory manifestations such as pharyngitis, laryngitis or upper respiratory infection. Code 487.0 for reporting influenza with pneumonia is also still valid.
When providing in-office testing for influenza, code 87804QW represents CLIA-waived testing for influenza by immunoassay with direct optical observation. Most rapid tests do not differentiate between Influenza A and B. However, for those that do produce two separate results, payers may accept 87804QW on one claim line and 87804QW59 on a separate claim line. As always, you should check with your individual payers for specific coverage and billing guidelines.
Medicare's limiting charge
What are the Medicare guidelines in reference to rounding the maximum limiting charge to the nearest dollar?
Non-participating physicians may round the charges to the nearest dollar (i.e., round down if 49 cents or lower and up if 50 cents or higher) if they do so for all services, according to the Medicare Claims Processing Manual, Chapter 1, Section 126.96.36.199.
Editor's note: While this department attempts to provide accurate, useful information, some payers may not agree with the advice given. You should also refer to current CPT and ICD-9 manuals and payer policies.
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Send questions and comments to firstname.lastname@example.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
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