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H1N1 Vaccination Coding and Billing
Since the federal government is supplying H1N1 vaccine to health care providers at no cost, health plans will not pay providers for the vaccine itself. However, administration of the vaccine can be billed to health plans. See below for details about health plan coverage of influenza vaccine administration as well as applicable coding for vaccine administration.
H1N1 Vaccine Coding
CPT Codes (Note: the vaccine itself will not be covered by health plans, as providers receive the vaccine at no cost)
- 90470 - H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
- 90663 - Influenza virus vaccine, pandemic formulation, H1N1
HCPCS Codes (Note: the vaccine itself will not be covered by health plans, as providers receive the vaccine at no cost)
- G9141 - Influenza A (H1N1) immunization administration, including counseling when performed
- G9142 - Influenza A (H1N1) vaccine, any route of administration
ICD-9 Diagnosis Code: V04.81 (influenza)
Hospitals and other ancillary providers should bill using standard billing processes for vaccine administration. Hospitals and facilities should report H1N1 vaccine administration with revenue code 0771, Vaccine Administration, along with either 90470 or G9141.
For more detailed coding information from the state, see www.oregon.gov/DHS/ph/acd/flu/h1n1flu-subcommittee.shtml#tool.
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Aetna
Aetna will cover H1N1 flu vaccine administration 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. Aetna will 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. Copays, coinsurance and deductibles will not apply for the administration of the vaccine. Based on CDC recommendations, Aetna will pay for the administration of one or two doses of the H1N1 flu vaccine.
Aetna plans that include a pharmacy benefit that covers brand-name drugs will cover Tamiflu and/or Relenza for treatment of a diagnosis, or as a preventive measure as prescribed by a health care provider. Member co-payments or coinsurance are applied as noted in the member's benefit plan. For members who are in an Aetna pharmacy plan that covers only generic medications, Tamiflu and/or Relenza would be covered at the brand tier. This could result in a higher out-of-pocket cost for the member.
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Health Net
Health Net will only reimburse for vaccine administration. The benefit will be covered under the immunization benefit. No authorization will be required. Member responsibility (deductible, copay, coinsurance) will be applied.
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LifeWise
LifeWise is waiving cost shares associated with the H1N1 vaccination for fully insured group and individual members. They will also cover the H1N1 vaccination for fully-insured members who may have already reached their preventive care benefit maximum or whose plan does not include an immunization benefit. LifeWise is waiving the cost of administering the H1N1 vaccine to all fully insured group and individual members beginning October 1, 2009 through June 30, 2010. The waiver of the cost share is for the fee that a provider or pharmacy charges for administering the H1N1 vaccine. If a provider charges an office visit fee, the applicable benefit and cost shares will apply for the office visit.
Most LifeWise benefit plans include coverage for seasonal flu shots under preventive care benefits, subject to applicable plan limitations, copay, deductibles, coinsurance and eligibility at the time of service. In addition, members can now be reimbursed for their seasonal flu shot at locations other than their provider’s office, including grocery markets and pharmacies, simply by submitting a claim.
Medications used to treat influenza are also covered by LifeWise, subject to the normal provisions of each plan contract. Oseltamivir (Tamiflu) or zanimivir (Relenza) – recommended by Centers for Disease Control for treatment of the current H1N1 flu – are covered on group and individual plans that include prescription drug coverage. The level of coverage may vary by plan, but in a typical group plan with a tiered copay structure, oseltamivir (Tamiflu) is a preferred Tier 2 drug and zanimivir (Relenza) is a Tier 3 drug.
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ODS
ODS will cover the administrative fee for the vaccination on their insured business. The reimbursement will be based on plan design. Co-payments and/or coinsurance may vary by plan design.
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PacificSource
PacificSource will cover the administration fee for H1N1 vaccine at 100 percent of the allowed fee for all members insured under a medical group or individual policy (except for Short Term policies). Copays, coinsurance, deductibles, and preventive care benefit maximums will be waived.
Tamiflu and Relenza will be covered under the pharmacy benefit as Preferred Brand drug, subject to any quantity limits. Regular seasonal flu vaccines will continue to be covered based on the member’s medical and/or pharmacy plan design.
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Providence
If a Providence provider is chosen to give the vaccine, Providence will pay them the same administration fee that they would for the seasonal flu.
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Regence
Regence will provide coverage for the costs associated with the administration of the H1N1 vaccine, waiving co-pays and deductibles for all members covered by its insured plans. Regence will strongly encourage self-insured employers to cover the full cost to ensure that the greatest number of people are protected.
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United Healthcare
United Healthcare and its affiliated companies will reimburse for the administrative costs of H1N1 vaccine administration, regardless of the individual's benefit plan. United Healthcare is waiving deductibles and providing coverage for services rendered by out-of-network physicians, public clinics and pharmacies. Continuously updated information about United Healthcare's H1N1 initiatives, billing guidance and other information is available at www.unitedhealthcareonline.com.
To ensure proper processing, please include your allowable charge for 90663 or G9142 at $0.01. Services billed with vaccine allowable charges at $0.00 may not be processed. United Healthcare is advising physicians ant other practitioners billing on a CMS 1500 or UB04 to submit the vaccine code with $0.01.
United will reimburse Evaluation and Management services per the individual's benefit plan. Vaccine administration services rendered on the same day as E&M services will be reimbursed.
United Healthcare, SecureHorizons, Evercare, AARP MedicareComplete and AmeriChoice will cover the seasonal flu vaccine and administration in accordance with a member's benefit plan.
For groups that have the UnitedHealthcare prescription benefit plan managed through UnitedHealthcare Pharmaceutical Solutions, Tamiflu and Relenza are covered drugs. The drugs are also covered under Legacy PacifiCare and UnitedHealthcare prescription benefit plans administered by Prescription Solutions, which have lifted all prior authorization requirements until further notice. H1N1 member FAQs are available at www.uhc.com/news_room/swine_flu_advisory/swine_flu_faq.htm.
On April 26, 2010 United Healthcare issued a memo and list of Frequently Asked Questions that discuss the end of emergency measures established last fall in response to H1N1 flu. Click here to accese these resources.
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Medicare Part B (Noridian)
The H1N1 vaccine will be provided to Medicare Part B beneficiaries as an additional preventive immunization service. Medicare will pay for the administration of the H1N1 vaccine. In the event that it is necessary for Medicare beneficiaries to receive both a seasonal flu vaccination and an influenza A (H1N1) vaccination, then Medicare will pay for both. For this upcoming flu season, Medicare will reimburse Medicare beneficiaries, up to the fee schedule amount, for the administration of H1N1 influenza vaccine, when furnished by a provider not enrolled in Medicare. Medicare will pay for seasonal flu vaccinations even if the vaccinations are rendered earlier in the year than normal.
Payment of G9141, Influenza A (H1N1) immunization administration, will be paid at the same rate established for G0008 (administration of influenza virus vaccine). The same billing rules apply to the H1N1 vaccine as the seasonal flu, except Medicare will not pay providers for the vaccine, since the vaccine is available at not cost to providers. Providers do not need to use the G9142 (H1N1 vaccine code) on the claim. Payments will not be made to providers for office visits when the only purpose of the visit is to administer either seasonal and/or H1N1 vaccines.
For Medicare Part B, H1N1 administration claims will be processed using the diagnosis V04.81 (influenza), and depending on the provider type, using revenue code 771.
Providers who normally participate in the Medicare Part B program as mass immunizer roster billers and mass immunizer centralized billers may submit H1N1 administration claims using the roster billing format. The same information must be captured for H1N1 roster claims as for the seasonal flu roster claims.
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Medicaid
DMAP will reimburse providers for administration of H1N1 vaccinations. Administration should be billed with the code 90470 - H1N1 immunization administration (intramuscula, intranasal), including counseling when performed. Bill the vaccine with code 90663 with modifier SL and without a charge.
For Oregon Health Plan clients age 0-18, seasonal flu vaccine serum is provided at no cost under the federal Vaccines for Children (VFC) program. DMAP will reimburse for the administration of VFC vaccines, but only to providers enrolled with the VFC program. To enroll as a VFC provider, call (971) 673-0300. For more information about the VFC program, go to www.oregon.gov/DHS/ph/imm/vfc/index.shtml. For each administration, bill the specific vaccination code, and add modifier -26 or -SL.
For OHP clients age 19 and older, DMAP will reimburse providers for seasonal flu administration and vaccine. Use standard billing procedures.
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