Flu Shot CPT/HCPCS, ICD Codes with Medicare Allowables

Learn CPT Codes used for Medicare billing of Influenza Vaccines, commonly known as Flu Shots. You can also check out our article on Influenza/Pneumococcal Billing & Reimbursement in 2011.

Influenza (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.

Centers for Medicare & Medicaid Services (CMS) no longer recognize and reimburse CPT Code 90658 Influenza Virus Vaccine, Split Virus for flu shots. CMS has established five separate influenza vaccine HCPCS codes to distinguish between the brand-names of influenza vaccines for governmental tracking purposes. Make sure to use these new codes in your medical billing.

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. Most types of injections, including a vaccine like the flu shot, are 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

Who should be vaccinated

Although it’s true that the vaccine does not protect 100% of those who get it, it does protect most from life-threatening illness. The advisory committee on immunization practices (ACIP) recommends universal seasonal flu vaccination for anyone age 6 months and older.

1. It includes age 6 months through 4 years (59 months).
2. Older than 50 years with chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic, hematologic or metabolic disorders (including diabetes mellitus).
3. Pregnant women who are Immunosuppressed (including immunosuppression caused by medications or by human immunodeficiency virus)
4. 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.
5. Residents of nursing homes and other chronic care.
6. American Indian/Alaska Natives
7. Those who are morbidly obese

Flu Shot ICD Codes for Diagnoses

Use ICD 9 diagnosis code V04.81 Prophylactic vaccination and inoculation against influenza. If you are giving Pneumococcus and Influenza vaccinations on the same date, use ICD code 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.

New HCPCS Medicare Flu Shot Codes

HCPCS Code G0008 Administration of Influenza Virus Vaccine must still be used for the administration of the flu vaccine for Medicare patients. Below are the most commonly used Medicare Flu Shots CPT Codes:

• Q2035 Afluria Vaccine
  Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
  
  
• Q2036 Flulaval Vaccine
  Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
  
  
• Q2037 Fluvirin Vaccine
  Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
  
  
• Q2038 Fluzone Vaccine
  Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
  
  
• Q2039 NOS (Not Otherwise Specified) Vaccine
  Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)
  

Medicare Allowable CPT/HCPCS Brand

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. Below are the CPT/HCPCS brand with their Medicare allowables against them for Medicare Flu Shots Reimbursement:

• 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 Medicare: FluBlok (Pending)
• Q2035 Medicare: Afluria ($11.543)
• Q2036 Medicare: FluLaval ($8.579)
• Q2037 Medicare: Fluvirin ($14.963)
• Q2038 Medicare: Fluzone ($12.044)
• Q2039 Medicare: Adult, not otherwise specified (locally determined)

The national average for Medicare payment allowance may vary by geographical location and you will need to check the CMS Fee Schedule for your correct reimbursement rate. The HCPCS codes Q2035 & Q2039 do not have national payment limits and will be determined by the local Medicare carrier.