Everything you need to know about billing for the flu shot this season, including CPT and HCPCS codes by brand and dosage, and the appropriate administration and diagnosis codes.

1. FALL 2013 & WINTER 2014
ALL ABOUT
BILLING FOR FLU
SHOTS
Mary Pat Whaley, FACMPE, CPC
President, ManageMyPractice.com
(919) 370-0504

2. WHAT IS THE FLU?
Influenza, also called the "flu," is a contagious
respiratory illness caused by influenza viruses. There are
over 200,000 hospitalizations from influenza annually. An
average of 36,000 Americans die annually due to
influenza and its complications – most are people 65
years of age and over. The best way to prevent the flu is
to get vaccinated each year during the fall season.

3. WHO SHOULD BE
VACCINATED?
THE ADVISORY COMMITTEE
ON IMMUNIZATION
PRACTICES (ACIP)
RECOMMENDS UNIVERSAL
SEASONAL FLU
VACCINATION FOR ANYONE
AGE 6 MONTHS AND OLDER.

4. “THE MAJORITY OF THE 150+ CHILDREN WHO
DIES LAST YEAR FROM THE FLU IN THIS COUNTRY
WERE NOT VACCINATED. AND ALTHOUGH IT’S
TRUE THAT THE VACCINE DOESN’T PROTECT 100%
OF THOSE WHO GET IT, IT DOES PROTECT MOST
FROM LIFE-THREATENING ILLNESS.”
DR. WENDY SUE SWANSON,
“SEATTLE MAMA DOC”
FOR MORE FROM SEATTLE MAMA DOC, CLICK HERE

5.  Age 6 months through 4 years (59
months)
 Age >50 years with chronic
pulmonary (including asthma),
cardiovascular (except hypertension),
renal, hepatic, neurologic,
hematologic or metabolic disorders
(including diabetes mellitus.)
WHO SHOULD BE
VACCINATED?

6.  Are or will be pregnant
during influenza season
 Immunosuppressed
(including immunosuppression
caused by medications or by
human immunodeficiency
virus)
WHO SHOULD BE VACCINATED?

7.  Age 6 months through 18 years
using long-term aspirin therapy
and who might be at risk for
experiencing REYE SYNDROME
after flu virus infection.
 Residents of nursing homes
and other chronic care
 American Indian/Alaska
Natives
 Those who are morbidly obese
WHO SHOULD BE VACCINATED?

8.  Healthcare personnel, household
contacts and caregivers of children
<5 years and >50 years old with
particular emphasis on vaccinating
contacts of children <6 months, and
household contacts and caregivers
of persons with medical conditions
that puts them at a higher risk for
severe complications.
WHO SHOULD BE VACCINATED?

9.  PATIENTS WITH A SEVERE ALLERGY TO EGGS –
HOWEVER THERE IS A NEW ADULT-ONLY VACCINE
CALLED FLUBLOK FOR THOSE WITH EGG ALLERGY
FEVER OR MODERATE TO SEVERE ILLNESS AT THE
TIME OF VACCINATION
HISTORY OF GUILLAIN-BARRE SYNDROME AFTER
PREVIOUS FLU VACCINES
PREVIOUS ALLERGIC REACTION TO A FLU SHOT
WHO SHOULD NOT BE VACCINATED?

10. The flu season extends from September to March.
Seasonal flu vaccination should begin as soon as
vaccine is available (usually early September) and
continue throughout the flu season. Seasonal flu
outbreaks can happen as early as October, and
seasonal flu activity usually peaks during the winter.
WHEN SHOULD
EVERYONE GET
VACCINATED?

11. Most types of injections, including a vaccine like the flu
shot, is billed using two codes:
Part One: A code for the flu vaccine itself, whether it is
a liquid to be injected, or a mist that is to be inhaled.
Part Two: A code for The administration of the injection
BILLING FOR FLU SHOTS - BASICS

12. Some payers do not recognize the value of the
administration of any vaccine, and will not pay a
separate amount for administration, however,
most payers, including Medicare, will reimburse
for both the vaccine itself and the administration.
BILLING FOR FLU SHOTS -
ADMINISTRATION

13. INJECTION: 90471 – IMMUNIZATION ADMINISTRATION
(INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS OR
INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION
VACCINE/TOXOID) **NOTE: IF GIVING TWO VACCINES, USE 90471 FOR
THE FIRST AND 90472 FOR EACH ADDITIONAL VACCINE
ADMINISTRATION.
INTRANASAL: 90473 – IMMUNIZATION ADMINISTRATION
BY INTRANASAL OR ORAL ROUTE; 1 VACCINE (SINGLE OR
COMBINATION TOXOID) **NOTE: IF GIVING TWO VACCINES, USE
90473 FOR THE FIRST AND 90474 FOR EACH ADDITIONAL VACCINE
ADMINISTRATION.
BILLING FOR FLU SHOTS -
ADMINISTRATION

14. G0008 – IMMUNIZATION ADMINISTRATION FOR MEDICARE
ONLY
**NOTE: CHECK WITH MEDICARE REPLACEMENT PLANS TO
SEE WHICH ADMINISTRATION AND VACCINE CODE THEY
PREFER.
BILLING FOR FLU SHOTS -
ADMINISTRATION

15. NOTE: THERE IS A DIFFERENT CODE USED FOR
IMMUNIZATION ADMINISTRATION FOR PATIENTS AGE
18 AND YOUNGER, IF THE PROVIDER COUNSELS THE
PATIENT/FAMILY ON THE VACCINE (SEE CPT CODES
90460 & 90461.) THESE CODES REPLACE THE
STANDARD IMMUNIZATION ADMINISTRATION CODES.
BILLING FOR FLU SHOTS - COUNSELING

16. In previous years there has been a lot of confusion whether
insurance plans covered the flu shot and if they did, if the
deductible, co-pay or co-insurance was applicable.
This year, things are much easier now that preventive care,
including the flu shot, are covered by almost all plans, and no
deductible, co-pay or co-insurance applies, courtesy of the
AFFORDABLE CARE ACT.
For patients without insurance, most practices price the
vaccine and administration at $25 to $45 per flu shot,
depending on the cost of the vaccine they are
BILLING FOR FLU SHOTS -
COLLECTIONS

17. For patients with Medicare Part B, the plan will cover one
flu shot per flu season in the fall or winter. Medicare
patients pay NOTHING for a flu shot if the doctor or other
qualified health care provider accepts assignment for giving
the shot. Medicare may cover additional seasonal influenza
virus vaccinations if medically necessary.
BILLING FOR FLU SHOTS - MEDICARE

18. The allowances on the following slide are based on 95% of
the AWP (average wholesale price) and do not apply to flu
shots furnished in a hospital outpatient department, a Rural
Health Clinic (RHC), or a Federally Qualified Health Center
(FQHC) for which payment is based on reasonable cost.
BILLING FOR FLU SHOTS -
ALLOWABLES

19. CPT/HCPCS Brand Medicare Allowable
90654 Fluzone 18.918
90655 Fluzone 17.243
90656 Afluria, Fluarix, Fluvirin, Fluzone 12.398
90657 Fluzone 6.022
90658 Afluria, FluLavil, Fluvirin, Fluzone See Q-codes below
90661 Flucelvax 20.663
90662 Fluzone 31.823
90672 FluMist 24.596
90673 FluBlok Pending
90685 Fluzone 23.228
90686 Fluarix, Fluzone 19.409
90687 Pending Pending
90688 FluLaval Pending
Q2033 (M’care) FluBlok Pending
Q2035 (M’care) Afluria 11.543
Q2036 (M’care) FluLaval 8.579
Q2037 (M’care) Fluvirin 14.963
Q2038 (M’care) Fluzone 12.044
Q2039 (M’care) Adult, not otherwise specified Locally determined
BILLING FOR FLU SHOTS – MEDICARE ALLOWABLES

20. INFLUENZA VACCINE PRODUCTS/CODES
FOR THE 2013–2014 INFLUENZA SEASON
For a detailed, printable chart of all available vaccine
products with dosages, click on the link below.
BILLING FOR FLU SHOTS – MATCH THE
BRAND

21. Use diagnosis code (ICD-9) V04.81: "Prophylactic vaccination
and inoculation against influenza” When giving
Pneumococcus and Influenza vaccinations on the same date,
use V06.6.
When giving a vaccination at the same time as seeing a
patient for a medically necessary office visit, use a modifier
25 on the E/M code and map the E/M to a diagnosis code
that describes the reason for the visit.
BILLING FOR FLU SHOTS – DIAGNOSES

22. GET A FLU SHOT WIDGET LIKE THE ONE BELOW
FOR YOUR WEBSITE
FLU SHOT RESOURCES

23. CLICK HERE TO GO TO THE
FLU SHOT/VACCINE FINDER

24. CONTACT INFO:
Mary Pat Whaley, FACMPE, CPC
President, ManageMyPractice.com
(919) 370-0504
marypat@managemypractice.com

25. PHOTO CREDITS
Slide 2: Hospital
Slide 3: Toddler
Slide 5: Old Timey Child
Slide 6: Pregnant Mom
Slide 7: Couple
Slide 8: Caregiver
Slide 10: Calendar
Slide 11: Syringes