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Sunday, August 11, 2013

Flu Vaccine 2013: The story unfolds

photo source: Shutterstock
I wrote about this year's flu vaccine new twist last month (Flu Shot Information 2013-14 Season).

Since that time I've learned some frustrating things.

Although it is not new news that companies are making two types of injectable flu vaccine this season (trivalent and quadrivalent), there are signs that we won't be able to start using it. The quadrivalent vaccine was not approved by the FDA until after the CPT coding book was published for this year, so no currently recognized code exists for the quadrivalent vaccine. Since every service and procedure a physician's office does is reported to the insurance company with a CPT code, the quadrivalent vaccine can't be given and appropriately documented with appropriate notification to the insurance company. The codes (90685 for 6-35 months and 90686 for 36+ months) are now assigned for the quadrivalent vaccine in CPT 2014, but insurance companies have until January to recognize them (with a retroactive time of 90 days possible- so possibly as early as October they can be used, but with a question of reimbursement for this very real cost, many businesses will be hesitant to use it).

There is only one type of FluMist, so there is only one code, allowing it to be used when in stock. (For more on CPT codes: What Are CPT Codes?)

You might wonder why this is important. First, CPT codes are used to document which vaccine is given and to send it to the insurance company. We must report the code accurately for inventory, billing, and proper documentation reasons. Insurance companies value each code differently, so the vaccine reimbursement will be different from code to code (and also varies among various insurance companies). The quadrivalent vaccine is of course more expensive than the trivalent vaccine, but it also covers another strain of virus, which makes it a better vaccine.

Our office received notice that our first shipment of quadrivalent injectable vaccine would soon be shipped. Since we won't be able to use it, we were forced to cancel that order. (It was only a small fraction of our overall order, so we hope to have more coming later when this mess is sorted out.)

My biggest frustration is that I want my most at risk patients vaccinated with the quadrivalent vaccine because it covers an additional strain of influenza. They can't wait until January. Many of these kids are not able to get the FluMist because they are under 2 years of age. I will be forced to give kids the less-preferred (though still good) vaccine, fully knowing that the only reason is tied to coding and billing. I've had parents mention that they would pay cash to avoid the delay, but that gets complicated with insurance contracts.

And what about the companies that have made all of their pre-ordered quadrivalent vaccines? If we all cancel our orders, they will have invested time, money, and resources into an entire line of product that will go unsold. Over the years many manufactures have gotten out of the vaccine market due to it being a money loser (despite what some anti-vaccine people state of us being in it only for the money). For a historical review of why companies stop making vaccines, leading to shortages over the years, please see this article: Why Are Pharmaceutical Companies Gradually Abandoning Vaccines? I worry that this type of craziness will lead to future flu vaccine shortages, resulting in more people getting sick and dying from influenza.

That all being said, the FluMist recommendations have become more relaxed as we gain experience in how it affects at risk groups of people. Because it is a live attenuated vaccine, initially higher risk people were not eligible to get the vaccine out of fear it would lead to wheezing. It is still not recommended for children under 2 years of age, but other groups for whom it used to be not recommended now may consider it. Children over 2 years who have a history of wheezing, a weakened immune system, diabetes, and other higher risk conditions MAY be eligible for this vaccine. Pregnant women also used to not be eligible, but many OB's are now recommending it because of its superior protection, which helps protect the newborn as well. You will need to talk with your provider if you feel your child should get the FluMist but has historically been unable due to higher risk status.

So, in a nutshell: this flu season follows suit with the fact that there is always something crazy that happens with flu vaccines. This is the most frustrated I've been though. In years past it usually has to do with shortages and trying to get mass numbers vaccinated within a relatively small window of time. Things that really are beyond what anyone can do. We can't anticipate the need, so ordering (and manufacturing) isn't always matched to demand. Proper codes for a new vaccine that had been announced is something that should have been anticipated. These coding problems are due to something people should have addressed, not unknown issues, which is why I am more frustrated than ever!

Stay tuned...