A journalist called me recently and asked, “Why do you think there is such a high denial rate for Medicare for code 90471, immunization administration?  90471 is an active code in the Medicare Fee Schedule; why should there be so many denials?”

Experienced coders and billers could answer this journalist’s question in a heartbeat: Because Medicare pays for limited immunizations, and they have developed HCPCS codes to use for most of the covered immunizations.  This means practices need to use two sets of vaccine administration codes, and select the correct code based on the patient’s insurance.  Before we answer the question, let’s review immunization billing.

Medical practices use three sets of codes to report immunizations: the vaccines, the administration and Medicare-developed HCPCS codes for administration and some vaccines.

CPT vaccine codes: The first are CPT codes for the vaccines themselves, used if the practice has purchased the vaccines.   These vaccines or toxoids are in the code range of 90476 through 90749.   In addition, at the start of the CPT section on vaccines, the AMA notes that new vaccines are posted on their website twice a year.  Vaccine formulations change so frequently that the AMA does not wait for the publication of a new book.  Medical practices should use these vaccine codes to report the vaccine that is administered, when the vaccine was a cost to the practice.

States provide some vaccines for children, and in that case, report only the administration.  Some medical practices use the CPT vaccine codes with a one-cent charge in order to record in their practice management system what vaccine was administered.  In 2012, there was one new vaccine/toxoid code and two with revised descriptions.  All medical practices should review their charge slips at the start of each year to be sure that the vaccines listed on the slip match exactly the vaccines being administered. The sheer number of vaccines and combinations has increased significantly.

CPT administration codes:  In 2011, CPT changed the definition of vaccine administration codes.  There are two sets of administration codes with different definitions.  The first is 90460 and 90461 for administration to children up to age 18 by any route of administration with counseling by a physician or other qualified health care professional.  90460 is used for the first or only component of each vaccine or toxoid administered, and 90461 is an add-on code used for each additional vaccine or toxoid component.  CPT instructs us to use 90461 for each additional component in a given vaccine.  That means there could be two or three administration codes for a single multi-component vaccine.

The next set of vaccine administration codes are without counseling (90471—90474), used for any age group, and do differentiate between method of administration.  90471 and 90472 are used for an intradermal, subcutaneous or IM injections.  90471 is for the initial vaccine, single or combination and 90472 for each additional vaccine.  90473 is immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid.)  90474, and add-on code, is used for each additional vaccine/toxoid.

HCPCS vaccine and administration codes:  As if the CPT codes for administration and vaccines weren’t complicated enough, Medicare developed its own codes for vaccines and their administration.   When Medicare was authorized by Congress in the 1960s, it was for the care of sickness and injury, not for preventive services.  Over the years, Congress has added coverage for some preventive services such as flu vaccines.  In response, CMS developed its own codes for the vaccines it covers, to differentiate the services.  Medicare covers the seasonal flu vaccine, pneumococcal vaccine (or a combination of the two), and the hepatitis B vaccine under Part B Medicare.  Medicare covers herpes zoster vaccine under Part D Medicare—that is, not in a physician office billed to the Part B Contractor.

In order to get the flu, pneumoccal and hep B vaccines paid by Medicare, the medical practice must use HCPCS administration codes. (G0008 for influenza with diagnosis code V04.81; G0009 for pneumoccal with diagnosis code V03.82 and G0010 for hep B, with diagnosis code V05.3).   Use CPT codes for the vaccine/toxoid, except for Afluria, Flulaval, Fluvirin and Fluzone which have HCPCS codes.  These are listed on CMS’ quick reference information for Medicare Immunization Billing.

But, we’ve left our journalist without an answer.  Why might there be so many Medicare denials for 90471, vaccine administration?  Perhaps the group was using 90471 for a flu or pneumoccal vaccine administration, in which case Medicare would deny it.  Medicare requires the HCPCS codes for administration of those two toxoids.  Perhaps Medicare was denying 90471 when used to submit a herpes zoster vaccine.  Since that vaccine is a Part D benefit, both the vaccine and the administration will be denied in the office.  Or perhaps the practice was giving a patient a tetanus shot.  Medicare doesn’t cover a tetanus shot routinely (only after an injury) so the service could have been denied for that reason.

Medical practices can be paid for these services with a little preventive medicine of their own, insuring correct coding and billing:

• Review the code descriptions for administration;
• Review and update the vaccine/toxoid codes to reflect the ones currently in use in the practice; and
• Use HCPCS codes for Medicare patients.

Betsy Nicoletti, M.S., CPC, is the founder of Codapedia.com, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at www.mpconsulting.org.

You can watch an informational video by Betsy Nicoletti on Medical Billing Update: Three Tips to Improve Reimbursements now. She has also written recently on Compare and Contrast: Modifier 33 and Modifier PT and Preventive Services: How Practices Can Benefit from the Mandate