Coding for the H1N1 virus vaccination

October 23, 2009

Questions and answers dig into preparedness for a potential H1N1 influenza pandemic.

Key Points

Q: Will the Centers for Medicare & Medicaid Services release a written statement to beneficiaries and providers regarding Medicare's coverage of the H1N1 vaccine administration through Part B?

A: CMS will issue information that informs the public and its contractors concerning payment policy for the H1N1 vaccine and its administration under Medicare fee-for-service. Presently, the information available to CMS is that the H1N1 vaccine will be made available without charge to hospitals, physicians, and other entities that immunize patients. If that proves to be the case, then Medicare fee-for-service will not pay for the H1N1 vaccine. However, Medicare will pay for the administration of the vaccine in accordance with existing rules.

A: In general, billing for the administration of the H1N1 vaccine will be similar to billing for the administration of the seasonal flu vaccine. See CMS' Medicare Claims Processing Manual (Publication 100-04), Chapter 18, Section 10, at http://www.cms.hhs.gov/manuals/downloads/clm104c18.pdf.

The major difference in billing for the administration of the H1N1 vaccine is that if the H1N1 vaccine is made available to providers for free, then Medicare will not pay for the H1N1 vaccine itself. Therefore, the HCPCS code for the vaccine need not be included on the bill/claim submitted for payment of the administration of the vaccine.

The HCPCS code for the administration of the H1N1 vaccine is: G9141-Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family). 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 need not be appended to the bill/claim, if the provider elects to do so, the bill/claim will be accepted but the claim line for the vaccine will be denied.

The HCPCS code for the H1N1 influenza vaccine is: G9142-Influenza A (H1N1) vaccine, any route of administration.

Medicare systems will be programmed to pay for both a single dose of the seasonal flu vaccine, its administration, and for one or more administrations of the H1N1 vaccine (but again, not the H1N1 vaccine itself if it is supplied to providers free of charge). Payment will be subject to normal billing and payment rules that apply to influenza vaccine, including providers enrolled as mass immunizers to roster bill Medicare for H1N1 administration.

With regard to paying for diagnostic testing, Medicare will cover diagnostic tests consistent with existing policies, but it will not pay for non-covered services typically excluded for payment as an exception in an emergency or disaster situation. Medicare will not cover and pay for surgical masks.

Medical Economics Consultant Virginia Martin, vice president of operations for Reed Medical Systems in Monroe, Michigan, has more than 30 years of experience as a practice management consultant and is also a certified coding specialist, certified compliance officer, and a certified medical assistant. Have a coding or managed care question for our experts? Send it to meletters@advanstar.com.