Influenza A (H1N1) Virus Vaccine Update

Since the U.S. Food and Drug Administration (FDA) approved the Influenza A (H1N1) vaccine last month, it has been rolled out to a number of states in the country and is being administered. The Department of Defense (DoD) and TRICARE Management Activity (TMA) recently provided some guidance to TriWest Healthcare Alliance regarding the coverage and billing of the H1N1 vaccine.

TRICARE will cover this vaccine the same as any other Clinical Preventive service. The United States government is providing the H1N1 vaccine at no cost to providers, so TRICARE will only reimburse providers for the administration of the vaccine. Beneficiaries should not be billed for the vaccine or the administration of the vaccine; they will not have a cost-share or copay.

TRICARE has temporarily waived the requirement that a TRICARE beneficiary needs to obtain the H1N1 vaccine from a network provider. The requirement to obtain a referral/authorization from the beneficiary’s primary care manager (PCM) to obtain the H1N1 vaccine from a non-network provider is also waived. Note that this temporary waiver is for the H1N1 vaccine only and is only for the period October 1, 2009 through May 1, 2010.

Beneficiaries must obtain the vaccine from a TRICARE-authorized provider. TRICARE does not recognize the administration of flu vaccines in a civilian pharmacy, drugstore or other non-physician office locations. However, H1N1 vaccines may be administered by a TRICARE-authorized provider office or clinic that uses nurses to administer the vaccines with a supervising physician. Beneficiaries may contact their local military treatment facility (MTF) to determine whether the MTF will be obtaining the H1N1 vaccine and their priority for administering it.

H1N1 Virus Vaccine Billing

Effective for dates of service on and after September 1, 2009, the Centers for Medicare & Medicaid Services (CMS) has created the following new codes for Influenza A (H1N1):

• G9141 – Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
• G9142 – Influenza A (H1N1) vaccine, any route of administration
• 90470-H1N1 immunization administration (intramuscular, intranasal), including counseling when performed

The following code has also been revised to refer specifically to the H1N1 vaccine:

• 90663-Influenza virus vaccine, pandemic formulation, H1N1

Payment will be allowed for G9141 Influenza A (H1N1) immunization administration. The G9142 will be included on the Government No Pay List (GNPL) effective September 1, 2009. Providers do not need to bill the G9142 (HIN1 vaccine code) on their claim; however, if the G9142 is billed on the claim, only that claim line will be denied.

If an outpatient hospital dispenses the H1N1 vaccine, the facility should bill HCPCS code G9142 to follow the correct Outpatient Prospective Payment System (OPPS) requirements. If CPT code 90470 is billed, the line will be denied.

If you bill 90470 for the administration/counseling, you should also bill 90663 for the H1N1 vaccine even though CPT code 90663 will be denied since the government is providing the vaccine. TriWest will reimburse CPT code 90470 at the TRICARE maximum allowable rate (CMAC) for CPT code 90471.

CDC’s Advisory Committee on Immunization Practices (ACIP), a panel made up of medical and public health experts, has recommended the H1N1 influenza vaccine be administered to:

• Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated
• Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants less than 6 months old might help protect infants by “cocooning” them from the virus.
• Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity.
• All people from 6 months through 24 years of age
• Children from 6 months through 18 years of age because the CDC has seen many cases of novel H1N1 influenza in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread.
• Young adults 19 through 24 years of age because the CDC has seen many cases of novel H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population
• Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.

For more information about the H1N1 flu, go to CMS’s dedicated Web site at http://www.flu.gov/faq/swineflu/ or the CDC’s Web site at http://www.cdc.gov/H1N1FLU/.

Published Date: 10/14/2009