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H1N1 Coding and Payment Information

October 21, 2009

ACP Guidance on How to Code for Administering the H1N1 Vaccine

In preparation for an H1N1 influenza outbreak, the CDC will be providing the vaccine and ancillary supplies for free to CDC Public Health Emergency Preparedness grantees, otherwise known as project area designated sites.

Because the federal government will be paying for the vaccine itself, health insurers are only planning to reimburse for administration of the vaccine. Most of the country’s large insurers, including Medicare, will be covering the administration, but with varying degrees of comprehensiveness.

One of several CPT procedure codes will apply to the immunization administration:

• CPT codes 90465-90468, Immunization administration for patients younger than 8 years
• CPT code 90470, H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
• CPT codes 90471-90474, Immunization administration
• HCPCS code G9141, Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

When billing Medicare or Medicaid, the new HCPCS code, G9141, should be used. If you do not use this code, the portion of the claim for the vaccine will be denied. Medicare and Medicaid reimbursement will be similar to the seasonal influenza vaccine administration in that the beneficiaries’ deductibles and copayments do not apply to the vaccine administration. CMS offers additional information on its Web site.

Most private payers will be covering the vaccine administration and they are rolling out their coverage guidelines.

CIGNA has already issued guidance and it will be covering the vaccine administration for insured-plan customers at 100% with no copayment, prior authorization, or co-insurance. CIGNA is also working with its self-insured employers in its role as third-party administrator to encourage them to cover the full cost of the vaccine administration. Further information about CIGNA's guidance is available online.

UnitedHealthcare’s H1N1 flu vaccine coverage policy is at https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/H1N1/H1N1_letter_FAQ.pdf

To review Aetna’s policy click here.

An American Medical Association-compiled table provides quick reference to policies for additional prominent payers.

Acrobat PDF format. Download Acrobat Reader software for free from Adobe. Problems with PDFs?

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