Health Information Management

Q/A: Assigning HCPCS code for H1N1 vaccine

APCs Insider, May 20, 2011

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Q: We provide H1N1 immunizations in our hospital’s outpatient setting and we understand that the vaccine is free. However, whether to charge for and assign the HCPCS code for the vaccine product,  administration of the vaccine, or both remains a subject of debate.

A: HCPCS code G9142 (influenza A (H1N1) vaccine, any route of administration) may not be reported under Outpatient Prospective Payment System (OPPS) because its status indicator is E. This status indicator provides that the HCPCS code in question is not covered, not recognized, or is not eligible for separate payment under OPPS. 

Hospitals that secure this drug product at no cost may not charge for it because it didn’t cost them anything; and this is the reason for assigning status indicator E. Submitting bill type 131 will trigger an edit because G9142 will not pass through the Outpatient Code Editor (OCE). Appending modifier -GY to HCPCS G9142 is inappropriate because the vaccine is a covered service procured at no cost.

HCPCS code G9141 (influenza A [H1N1] immunization administration [includes the physician counseling the patient/family]) was created for the administration of the H1N1 vaccine to Medicare patients. HCPCS G9141 supersedes CPT codes 90471-90474, which are defined as vaccine administration. Therefore, when a Medicare patient receives an injection of H1N1 vaccine, you should report the administration with HCPCS G9141 under revenue code 0771, and the associated charge for the administration. The service is paid through Ambulatory Payment Classification (APC) Group 0350 with national unadjusted payment of $26.35.

Transmittal 1803, October 1, 2009, states:

Under the OPPS, HCPCS code G9142 will be assigned status indicator “E,” indicating that payment will not be made by Medicare when this code is submitted on an outpatient bill type because we anticipate that the H1N1 vaccine will be supplied at no cost to providers. Payment will be made to a provider for the administration of the H1N1 vaccine, even if the vaccine is supplied at no cost to the provider. Beneficiary copayment and deductible do not apply to HCPCS code G9141 (for both OPPS and non OPPS providers), and we are assigning HCPCS code G9141 to APC 0350 (Administration of Flu and PPV Vaccine) with a payment rate of $24.89 for CY 2009. Providers should report one unit of HCPCS code G9141 for each administration of the H1N1 vaccine.

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