Payment and Coding

​Infl​uenza Implementation Guidance


Updated September 2020

​Paym​ent and Coding

Payment

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 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. 

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. As guidance in obtaining payment for vaccines and their administration, practices are advised to:

  1. 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 should verify with the carriers how they will incorporate new recommendations into the benefits coverage and fee schedule so as not to delay payment.

  2. 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 third-party payers will base 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.

  3. 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). 

  4. In addition to the payment for the vaccine and related expenses, make sure the contract provides payment for immunization administration, which is a separate expense. For information on the total expenses for immunization administration, see AAP The Business Case for Pricing Immunization Administration (Member benefit, log- in required).  

  5. 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:

    1. Are eligible for Medicaid (in some states only Title 19 recipients are eligible for VFC),
    2. Have no health insurance,
    3. Are American Indian or Alaska Native, or
    4. Are underinsured.

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

  6. AAP chapters and/or their pediatrics councils may decide to also follow up with the state Medicaid and CHIP 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. 

  7. The AAP supports efforts to overcome payment barriers impacting pediatric practices from providing influenza vaccine to parents and other adult caregivers of children. To facilitate claims processing payment and immunization data exchange, pediatric practices should maintain separate medical records for parents and other adult caregivers documenting the vaccination.  

  8. 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 at  Waivers: The Basics for a Pediatric Office. (Member benefit, login required).

Coding

Reporting for the 2020-2021 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 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. 

Product

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

  1. Route of administration (eg, intramuscular (IM), intranasal)

  2. Dose (.25ml or 0.5ml)

  3. Preservative or preservative-free vaccine

  4. 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.  



Administration

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.”



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).


Coding Vignette for Immunization Administration Codes Only

  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) 

  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

  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).

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