Each practice should verify with third-party payers whether the influenza vaccine is a covered benefit and how it will be paid. Third-party payers include commercial insurers, Medicaid fee for service, and Medicaid managed care. 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. Generally, most third-party 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. Until recommendations are published, those health plan claims systems do not recognize the vaccine as a covered benefit. As guidance in obtaining payment for vaccines and their administration, practices are advised to:
Review each contract with third-party payers and its vaccine coverage provisions to make sure it includes a clause allowing mid-contract inclusion of new immunization recommendations. If there are no contract provisions on adding new immunization recommendations, you will need to verify with the carriers how they will incorporate new recommendations into the benefits coverage and fee schedule so as not to delay payment.
Review the fee schedules and contracts regarding payment levels for vaccines. Make sure there is a provision in the fee schedule that allows for payment to be in an amount equal to the sum of both the cost of the vaccine and related practice expenses to store the vaccine(s). Some carriers will base health-plan payment at a level of average wholesale price (AWP) or average sales price (ASP). It is important to identify the source of the AWP or ASP, as there are several vendors providing these figures, as well as verify that the current AWP or ASP is being referenced. The AAP supports use of the CDC Vaccine Private Sector price list as the basis for the vaccine cost as this lists the manufacturer's current vaccine price. Unlike sources of AWP, the CDC private payer vaccine price list is not proprietary and is a more readily transparent source of actual vaccine acquisition costs. It is based on the manufacturer's price for vaccines and is updated as soon as price changes are reported as opposed to ASP and AWP, which are updated quarterly.
Include a provision in the contract for the health plan to pay no less than the vaccine acquisition cost plus related practice-expense costs. For information on the total costs related to the vaccine product, see the AAP Business Case for Pricing Vaccines. (Member benefit, log-in required). Sample contract language on vaccines is available in the AAP Vaccine Addendum to Payer Contracts. (Member benefit, log-in required).
In addition to the payment for the vaccine and related expenses, make sure the contract provides payment for the immunization administration, which is a separate expense. For information on the total expenses for immunization administration, see The Business Case for Pricing Immunization Administration (Member benefit, log- in required).
VFC 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:
Are eligible for Medicaid (in some states only Title 19 recipients are eligible for VFC)
Have no health insurance
Are Native American or Alaska Native, or
Have health insurance, but it does not cover immunizations AND they go to a Federally Qualified Health Center
AAP chapters and/or their pediatrics councils may decide to also follow up with the state Medicaid and Children's Health Insurance Programs, respectively, to ensure coverage of the vaccine, its administration, and practice-related expenses. Children eligible for Medicaid should receive the vaccine through the VFC program. The AAP has developed The Business Case for Pricing Immunization Administration in a Federal or State Supplied Environment to inform payers and practices of the practice expenses that need to be covered and paid when vaccines are provided to the practice.
Develop payment arrangements with families if coverage is not available through a third-party payer. Consider having families sign waivers or advance beneficiary notices specifying their financial responsibility for services not covered by their health plan. Additional information on waivers can be found on My AAP, private payer advocacy page under Waivers: The Basics for a Pediatric Office. (Member benefit, login required).
Reporting for the 2019-2020 seasonal influenza vaccine products will be more streamlined this year. Current Procedural Terminology (CPT®) codes have been added to the list for those pediatric influenza vaccines that have been confirmed to be manufactured for 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, 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 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
If both of the above criteria are not met, report the appropriate code from the 90471-90474 series. 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).
1. A 12-year old presents for her second HPV vaccine and her yearly influenza vaccine. She sees an RN who reviews contraindications and briefly counsels on the vaccines. Both are then administered.
Report 90471 (HPV) and 90474 (Influenza, intranasal)
Note: Because the RN is not another qualified healthcare professional, you cannot report the 90460 unless otherwise directed by your payer in writing.
2. If the same patient above had seen a physician or qualified healthcare professional and there was documented counseling for both vaccines, the vaccine administration codes would be as follows:
Report 90460 with 2 units (HPV and influenza)
Note: Regardless of route of administration, the 90460 can be reported so long as the patient is 18 years of age or younger and there is documented physician or other qualified healthcare professional counseling.
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