H1N1 Administration Coding

In an effort to support the federal government's initiative to provide H1N1 vaccination to the public, the American Medical Association's Current Procedural Terminology (CPT) Editorial Panel has approved code 90470, "H1N1 immunization administration (intramuscular, intranasal), including counseling when performed." The code is effective immediately as of 09/25/09. The Editorial Panel also revised code 90663 to specifically refer to the H1N1 vaccine itself rather than a generic pandemic influenza virus vaccine.

So what does this mean? Should you ignore previous instructions from payers? The AAFP is working on your behalf to find out and provide that information on this web page.

Here's what we know as of 10/26/09:

Code V04.81 is the diagnosis code for both the seasonal and H1N1 vaccinations.

An evaluation and management (E/M) code should be reported on the same date as the vaccine administration codes only when a significant, separately identifiable E/M service is provided. To indicate a significant, separately identifiable E/M service, append modifier 25 to the E/M code reported.

According to H1N1 vaccine administration frequently asked questions from the CDC, "The H1N1 provider agreement states that the provider “may charge a fee for the administration of the vaccine to the patient, their health insurance plan, or other third party payer. The administration fee cannot exceed the regional Medicare vaccine administration fee.” This means that the provider may not request out-of-pocket payment from a patient that is greater than the amount that Medicare reimburses for influenza vaccine administration in that jurisdiction. “Charge” refers to collecting an out-of-pocket payment from the patient.

However, the provider agreement does not dictate the level of reimbursement for vaccine administration that is provided by an insurance plan or payer. Providers should bill payers and insurance plans at their regular agreed-upon rates, and may accept whatever level of reimbursement is provided by a plan or payer for H1N1 vaccine administration."

Medicare created two new G codes to allow physicians providing the H1N1 to report the administration and, if desired, the vaccine itself. Medicare does not require reporting of a code for the vaccine because the vaccine is provided to physicians at no charge.

Medicare's G codes are:
G9141—Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

G9142—Influenza A (H1N1) vaccine, any route of administration

Note that Medicare will pay for administration of the H1N1 vaccine without application of deductible and coinsurance amounts (i.e., at 100% of allowable). The allowable for G9141 is the same as is paid for the seasonal flu vaccine administration code, G0008. Also, Medicare will cover administration of both vaccines provided on the same date. Use the appropriate code for the seasonal influenza vaccine product administered to report that product.

Humana will accept either code 90470 or G9141 for the H1N1 vaccine administration. It is not necessary to report a code for the vaccine itself.

Physicians will need to verify benefits as these will vary according to the patient's plan.

CIGNA is asking physicians to bill for the administration of H1N1 flu vaccines using CPT 90470 or G9141 code.

CIGNA will reimburse health care professionals and facilities for the administration of the H1N1 vaccine to all individuals covered under a fully-insured CIGNA medical benefit plan. CIGNA is strongly recommending all self-funded plans administered by CIGNA where the employer makes coverage policy decisions to also provide coverage for the administration of the vaccine.

CIGNA coverage for H1N1 vaccine administration will not be subject to plan deductibles, co-pay or coinsurance. Certain self-insured benefit plans administered by CIGNA may not adhere to this coverage policy.

Aetna instructs that the administration of the H1N1 vaccine should be reported using the appropriate CPT code 90470 or HCPCS code G9141.

Aetna will cover administration of the H1N1 flu vaccine for all fully insured medical plan members and self-funded plan members unless the plan sponsor decides otherwise. Aetna is offering this coverage even in instances where members' plans do not include coverage for preventive care or have limits on such coverage. Co-pays, co-insurance and deductibles will not apply for the administration of the vaccine.

UnitedHealthcare has instructed physicians to bill CPT code 90663 or G9142 for the H1N1 vaccine on claims for the administration of the vaccine with ICD-9 code V04.81 and a charge of .01 cent. Submission of .00 charged for the vaccine may not be processed. Claims should include the appropriate immunization administration code 90470 or G9141 in conjunction with code 90663 or G9142, respectively, for the administration of the vaccine. Use this same method for reporting a second dose of the vaccine on a different date.

Where state governments have provided billing instructions for Medicaid patients, please check AmeriChoice.com for the latest information on specific billing guidance.

You can assist with vaccine safety tracking by providing the National Drug Code (NDC) on your claim. Many practices may already do this for certain injectable drugs and vaccines due to Medicaid and other plan requirements. However, if you are not familiar with how to do so, the NDC goes on the paper 1500 claim form in the gray area above the service line for the vaccine, beginning in block number 24A.

When entering supplemental information for NDC, add in the following order: qualifier N4, 11-digit NDC code without hyphens, one space, unit/basis of measurement qualifier ML, quantity. The number of digits for the quantity is limited to eight digits before the decimal and three digits after the decimal. If entering a whole number, do not use a decimal. Do not use commas.

As an example, administration of one prefilled 0.25mL syringe of the first product listed below would include the NDC number 49281-0650-25 reported on the claim form as N449281065025 ML0.25.

NDC codes we have identified for H1N1 vaccine products:

Sanofi Pastuer Vaccine Products
49281-0650-25 (10 prefilled syringes 0.25mL each, no preservative)
49281-0650-70 (25 prefilled syringes 0.25mL each, no preservative)
49281-0650-50 (10 prefilled syringes 0.50mL each, no preservative)
49281-0650-90 (25 prefilled syringes 0.50mL each, no preservative)
49281-0650-10 (10 single dose vials 0.50mL each, no preservative)
49281-0640-15 (5.0mL vial)

MedImmune Vaccine Product
66019-0200-10 (10 prefilled sprayers)

CSL Products
33332-0519-01 (10 prefilled syringes 0.50mL, preservative-free)
33332-0290-10 (5.0mL vial)

Novartis Products
66521-0200-02 (10 prefilled syringes 0.50mL, preservative-free)
66521-0200-10 (5.0mL vial)

GSK Products
Forthcoming