American College of Physicians: Internal Medicine — Doctors for Adults ®

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Medicare, many insurers announce coding rules for H1N1

From the November ACP Internist, copyright 2009 by the American College of Physicians

By Debra Lansey

As part of their preparedness planning for an H1N1 flu outbreak this year, the CDC and the Department of Health and Human Services (HHS) will provide H1N1 vaccine and ancillary supplies, such as needles, syringes, alcohol swabs and sharps containers, free of charge to CDC Public Health Emergency Preparedness grantees, also called project area-designated sites, which include entities such as public and private clinics, offices and health departments. HHS is currently developing plans for ensuring the distribution of these products.

Most of the country’s largest health insurers will cover the costs of administering the H1N1 vaccine, in addition to covering the seasonal influenza vaccine and its administration costs. Because the federal government will pay for the H1N1 vaccine, health insurers are planning to reimburse, in varying degrees of comprehensiveness, only for its administration.

Q: What codes are available to bill insurers?

A: The most frequent billing guidance from insurers concerns only the administration of the vaccine. Because the federal government is supplying the vaccine itself, insurers do not expect to receive claims for the vaccine cost. But, if you are instructed to bill for the vaccine, use CPT 90663, Influenza virus vaccine, pandemic formulation for the vaccine. Looking at the overall patterns of vaccine provision and coding advice, you probably will not need to use CPT code 90663 on any of your claims.

The CDC notes that private providers of the vaccine cannot charge more for the administration fee than the regional Medicare vaccine administration fee. For the administration, use one of the procedure codes for immunization administration:

  • CPT codes 90465-90468, Immunization administration for patients younger than 8 years
  • CPT code 90470, H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
  • CPT codes 90471-90474, Immunization administration
  • HCPCS code G9141, Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

In consultation with the HHS, the American Medical Association CPT Editorial Panel created CPT code 90470 to report H1N1 immunization administration and counseling. This code was developed to meet the immediate needs of insurance payers whose claims systems require CPT codes, rather than HCPCS codes.

CPT code 90663, Influenza virus vaccine, pandemic formulation, H1N1, was revised by the CPT Editorial Panel to refer specifically to the H1N1 vaccine product. Both revised code 90663 and new code 90470 are effective immediately; there is no need to wait until January 2010 to use the codes.

As this article went to press, insurance plans were still announcing the details of their coverage. Check with payers to get up-to-date information.

Q: How should I bill private payers?

A: ACP obtained H1N1 vaccine administration coverage information from most of the largest health insurers, and much of their instructions are consistent with the Medicare guidance. As this article went to press, insurance plans were still announcing the details of their coverage.

Although this column contains the coding guidance from several very large insurers, there is no universal agreement among all insurers on which codes will be accepted, so check with insurers before submitting your claims.

Based on CDC recommendations, Aetna will pay for the administration of one or two doses of H1N1 flu vaccine, for members whose benefit plans cover preventive services. If a vaccine code is submitted to Aetna, the insurer will not pay for the H1N1 vaccine itself, because the vaccine is being supplied by the federal government at no charge. If a physician decides to list the vaccine on a claim anyway, they can use either CPT code 90663 or HCPCS code G9142. For the administration, they should use the age-appropriate CPT codes. Aetna will also pay for the seasonal flu shot and its administration on the same or different dates of service as the H1N1 vaccine, based on CDC recommendations.

CIGNA’s announcement differentiates its coverage for insured plans and self-insured plans (for which CIGNA is only the administrator). CIGNA will cover the H1N1 vaccine administration under the preventive care benefit for its insured-plan customers. H1N1 vaccine administration will be covered at 100% with no copayment, prior authorization, or co-insurance for people enrolled in insured health plans, where CIGNA funds an individual’s medical claims covered under the plan. For these plans, CIGNA will also reimburse the costs of the seasonal flu shot because the H1N1 vaccine is not intended to replace the seasonal flu vaccine; it is intended to be given in addition to the seasonal flu vaccine.

CIGNA, in its role as a third-party administrator, is working with its self-insured employers (the majority of its policyholders) to encourage them to cover the full cost and ensure that the greatest number of people are protected. Self-insured plans are an alternative to traditional insurance, and are used typically by very large companies as a means to keep costs down and tailor insurance to the needs of their own employees.

WellPoint will offer coverage for the administration of the H1N1 vaccine. The vaccine administration will be covered for members whose benefit plans cover vaccines. WellPoint will also continue coverage of seasonal flu vaccine administration for those whose health plans offer vaccine coverage. Seasonal flu and H1N1 vaccines may be administered on the same day.

Blue Shield of California will cover the administration costs of the H1N1 virus vaccine for all its members, regardless of which plan they are enrolled in. Blue Shield will waive prior authorizations, copayments, and deductibles for office visits when members go to an in-network doctor to obtain H1N1 vaccinations.

UnitedHealth Group will cover the administration of the H1N1 vaccine for its members whose health benefit plans cover immunizations. The insurer will also cover the administration of the vaccine for members whose plans currently do not include immunizations and do not plan to in the future.

Q: How should I bill Medicare and Medicaid for the H1N1 immunization costs?

A: Medicare and Medicaid laid out their payment policies for the H1N1 flu, and provided detailed coding guidance. In general, reimbursement for H1N1 vaccine administration will be similar to reimbursement for the seasonal flu vaccine administration, in that the beneficiaries’ deductibles and copayments do not apply to the vaccine administration (HCPCS code G9141). The new HCPCS code for the H1N1 vaccine administration is G9141. Payment for G9141 will be made at the same payment rate established for G0008 (Administration of influenza virus vaccine) for each administration. Although the HCPCS code for the H1N1 vaccine (G9142, Influenza A (H1N1) vaccine, any route of administration) does not need to be listed on the claim, if the physician elects to do so, the claim will be accepted but the claim line for the vaccine will be denied.

Under Medicare, H1N1 administration claims will be processed using the diagnosis V04.81 (influenza).

Medicare’s claims systems will be programmed to pay for both a single dose of the seasonal flu vaccine and its administration, and for one or more administrations of the H1N1 vaccine.

Medicare will pay for seasonal flu vaccinations even if the vaccinations are rendered earlier in the year than normal. The H1N1 virus vaccine will be provided to Medicare Part B beneficiaries as an additional preventive immunization service. Medicare will not reimburse physicians or other providers for office visits when the only purpose of the visit is to administer either the seasonal and/or the H1N1 vaccine(s).

Debra Lansey is Associate for Regulatory and Insurer Affairs for ACP.

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