Influenza Vaccines: Coding for the Current Season

Each practice should verify whether the influenza vaccine is a covered benefit and how it will be paid by all public and private payers, including private commercial insurers, self-insured plans, Medicaid fee-for-service, Medicaid managed care, Children's Health Insurance Programs (CHIP) plans, and TRICARE. Although the Affordable Care Act (ACA) allows for those enrolled in group or individual private health plans to be eligible to receive vaccines without any cost-sharing requirements when provided by an in-network provider, some plans such as grandfathered plans may be exempt from the ACA requirement. AAP chapters and/or pediatric councils may also decide to follow up with the state Medicaid and CHIP Programs, respectively, to ensure coverage of the vaccine, vaccine administration, and practice-related expenses.

Generally, most payers provide benefits coverage for vaccines based on published recommendations by the Advisory Committee on Immunization Practices (ACIP), AAP, and/or the American Academy of Family Physicians. The following is appropriate for those patients who are not Vaccines for Children (VFC) eligible patients. As guidance in obtaining payment for vaccines and their administration, practices are advised to do the following:

• Review each payer contract and vaccine coverage provisions to make sure new immunization recommendations will be covered and paid. If there are no contract provisions on adding new immunization recommendations, verify with carriers how they will incorporate new recommendations into the benefits coverage and fee schedule.
• Review each payer contract and applicable fee schedules to verify payment rates for vaccines. Payment should exceed the cost of the vaccine product and related overhead expenses, such as personnel costs to manage inventory or maintain documentation, or safe storage of vaccine products.
  • Note: some payers will base payment at a percentage of average wholesale price (AWP) or average sales price (ASP). Make sure to identify the source of the AWP or ASP, as there are several vendors providing these figures, and verify that the referenced AWP or ASP is current.
  • The CDC Vaccine Private Sector price list includes the manufacturer's current vaccine price and is updated as soon as price changes are reported, as opposed to sources of ASP and AWP which may be updated quarterly. Unlike sources of AWP, the CDC private payer vaccine price list is not proprietary and is a readily available, transparent source of actual vaccine acquisition costs.
• In addition to the payment for the vaccine product and related overhead expenses, make sure the contract provides payment for immunization administration, which entails separate work and practice expense, and is, therefore, separately reportable.
• Develop payment arrangements with families if coverage is not available through a third-party payer. Check your payer contract, provider manual, or payer policies for any language related to non-covered services. Depending on the language and any restrictions, consider having families sign waivers or advance beneficiary notices specifying their financial responsibility for services not covered by their health plan.
• For pediatric practices providing influenza vaccine to parents and other adult caregivers of children, maintain separate medical records for parents and other adult caregivers documenting the vaccination. This should help facilitate claims processing payment, immunization data exchange, and is a prudent medical liability risk management strategy.

The Vaccines for Children (VFC) Program is not an option for those children covered by private health insurance providing immunization benefits. This program is for children aged birth through 18 years who meet one or more of the eligibility criteria for VFC:

• Are eligible for Medicaid (in some states only Title 19 recipients are eligible for VFC)
• Have no health insurance
• Are American Indian or Alaska Native
• Are underinsured

For more information regarding VFC eligibility, visit the CDC website on VFC Eligibility Criteria.

Coding for the 2020-2021 seasonal influenza vaccine products will be more streamlined this year than in years past. Current Procedural Terminology (CPT®) codes have been added to the list for those pediatric influenza vaccines available this upcoming year. As a reminder, for private payers a CPT code for the product and the administration is required. For VFC/Medicaid eligible patients this may vary. Always refer to your state VFC/Medicaid policy on reporting vaccines.

It is important to remember when coding for the influenza vaccine that the following information is relayed to the coder or biller:

• Route of administration (eg, intramuscular (IM), intranasal)
• Dose (.25ml or 0.5ml)
• Preservative or preservative-free vaccine
• Other types of vaccines such as cell cultured or antibiotic free

The chart below will assist in reporting the most appropriate product code for the vaccine product being given.

In addition to the influenza vaccine product code, be sure to also report the appropriate immunization administration code(s).

Report 90460 for a patient who

• Is 18 years of age or younger AND
• Receives vaccine counseling by the physician or other qualified health care professional (excluding clinical staff).

If both of the above criteria are not met, report the appropriate code from the 90471-90474 series. These codes are reported “per vaccine.”

*Note 90461 is not listed because influenza is a single component vaccine.

Report 90471 if the influenza injection is given. If, however, the influenza vaccine is given in conjunction with other vaccines, and the above criteria are not met to report a 90460 for the influenza vaccine administration, report 90472 for the influenza injection.

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code for any vaccine given including influenza is Z23 (encounter for immunizations).

Vignette #1

• A 12-month-old presents for her well child check. She is due for her MMR, Varicella, Hepatitis A and influenza. The mom is counseled on all vaccines and consent is given.

• Report 90460 and 2 units of 90461 (MMR), 90460 for Hepatitis A, and 90460 (Influenza, regardless of route of administration)

Vignette #2

• The same patient returns for her 2nd influenza vaccine. She sees a nurse only when the mom states she has no questions or concerns and does not need to speak with the physician. Consent is obtained and the vaccine is given.

• Report 90471 for the injection influenza or Report 90473 for the intranasal

Vignette #3

• A 14-year-old presents for her 3rd HPV vaccine in the series. At the same time the influenza vaccine is due. The father gives consent to both and does not request physician counseling. The nurse counsels the father and patient on adverse reactions and when to call the office. The HPV is given along with the intranasal influenza vaccine.

• Report 90471 (HPV) and 90474 (intranasal)

Note: While the patient met the age criteria for reporting the 90460-90461 series, the patient or parent was not counseled by a physician or other qualified health care professional, therefore the 90471-90474 series is to be used. In addition, because a “first” code was used (90471) the “subsequent” intranasal code must be reported (90473).

Vignette #4

• A 15-year-old presents for the 3^rd HPV vaccine and declines counseling. In addition, she is counseled on and decides to receive her 1^st COVID vaccine (Pfizer).
• Report 90471 for the 3^rd HV and 0001A for the 1^st Pfizer COVID-19 vaccine admin.

Note at this time some payers may require modifier 59 (on 90471) even though there is no national edit on the codes. Follow your payer policy

• AAP Influenza Page
• AAP Vaccine Financing page
• Preparedness Checklist for Pediatric Practices (Step 12: Handle Vaccine Issues)
• Vaccine Coding Table
• Principles of Child Health Care Financing (Recommendations Related to Provider Payments)