Category Archives: Vaccinations

When Medicare says 365 days, they mean 365 days.

Gentle readers,

It is flu shot season. And do-the-physicals-on-your-Medicare patients-before-they-go-somewhere-else-and-another-office-bills-the-physical season. And I am seeing a lot of the same question from both my billing service providers, and from you, my gentle readers.

Specifically, you billed/coded the flu shots and physicals the way I taught you and they are still getting denied! What gives?

And here is your unfortunate answer.

Medicare will pay a flu shot once every 365 days. They will pay a physical once every 365 days. They will pay a pap once every 730 days for a woman at normal risk and once every 365 days for a woman at high risk. They will pay the pneumo vaccine once every 365 days.

That means that if a patient came in on Feb 17th 2016 to get their flu shot last year and then came in this year on Jan 25th and got another flu shot, you will not get paid. Even if you bill with ICD10 Z23. Even if you bill with the Q-code for the vaccine. Medicare does not care that it is a different flu season. They do not care that your patient will be visiting their newborn grandson in a couple weeks and they need to be up to date on their immunizations. They do not care that your patient is going for a month long cruise in the caribbean and this is the last date they have available until they get back and they would prefer to get it done before they are rubbing elbows with a bunch of strangers who may have the flu.

Medicare does not care.

And they really mean 365 days. Not 364. So, when a patient needs a preventive service, please try and train your doctors and your office staff to check the date the patient received their last preventive service. The Medicare site also has a tab under the eligibility lookup section to check and see when the patient is next eligible for a preventive service. Here is a screenshot of the page and what it looks like:

medicare-prev-screen-shot-1

As you can see, the date the patient is going to be eligible for any specific service is indicated on the right. Flu and Prevnar are not included in this list, so you will need to rely on your records to track those. 

Below is the link to a good website for more information on the Medicare policies for preventive services. 

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Keep emailing your questions and I’ll keep giving you answers. 

 

 

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Filed under Flu Shot, Immunizations, Medical Billing, Medicare, Preventative services, Vaccinations

How to bill Medicare HMOs

I know that is a very ambitious title, but a few people here have been emailing me with questions on this topic. I figure, if a few of my readers are taking the time to email me, then there are far more of you out there with questions. The good news is, the answer is fairly simple.

The emails I have been receiving fall into three main categories.

1. How do I bill a pap smear to a Medicare Risk HMO?

2. How do I bill flu shots/pneumococcal shots to a Medicare Risk HMO?

3. When Medicare says a patient has an HMO, is Medicare secondary?

And here are your answers:

1.  How do I bill a pap smear to a Medicare Risk HMO?

As you might remember from my previous post, Everything you ever wanted to know about pap smears, each HMO has its own way of doing things. Some want the diagnosis V72.31, others want V76.2. Some want to follow Medicare rules, and some want to pay with the preventative code.  Some won’t pay anything at all, instead they capitate it. The best way to find out how your HMO will pay your provider’s claim is to get a copy of the provider’s contract.  

2. How do I bill flu shots/pneumococcal shots to a Medicare Risk HMO?

By and large, the Medicare Risk HMO plans want us to use the Medicare codes for the flu and pneumonia substances. For the flu, use the Q-codes for the substance and the G0008 for the administration. For the pneumo, use 90732 for the substance and G0009 for the administration.  For a more thorough explanation, go take a look at my Medicare and Immunizations post.  Please remember, not all IPAs have the same fee schedule. If this doesn’t work, a quick call to the provider relations department will point you in the right direction.

3. When Medicare says a patient has an HMO, is Medicare secondary?

No.

Please, let me reiterate.

No. The HMO replaces the patient’s Medicare. The claims go to the HMO. We have to follow the HMO rules. The patient may have a copay and you may need an auth. I am training a front desk right now, and this is the policy I have in place.

If a new patient calls to make an appointment, check the insurance online while the patient is on the phone. It takes 30 seconds to check Medicare on the Noridian Endeavor site. If the patient has an HMO, make a note on the schedule and ask the patient to bring in their HMO card as well as their Medicare card.

If an established patient is returning to the office, go online and check the Medicare eligibility. The status of a patient’s Medicare can change month to month. PLEASE do not assume that if a patient had straight Medicare last month, he will again this month.

Once the doctor performs the service, good luck trying to collect from the patient. People hate to pay after they have already received their service.

So, as always, if you have any questions, please call or email. If you want us to come into your office and train your front desk or your billing department, we can do that. We do on-site training for those in our area and online training and Skype conferences for our far away clients.

EDIT: I have had a couple people ask me what you can do when you see the patient before you find out they have a MR Risk HMO.  You can try billing the patient your cash price. Or, you can send the claim to the IPA (medical group) with your medical records attached asking them to review the charge for a retro authorization based on medical necessity. In box 19 on the physical claim form write “please review notes for retro authorization.” I also like to send a letter. Here is a good example of a medical necessity template appeal letter. And everyone who gets paid due to this can thank Molly and David for their rather pertinent emails.

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Filed under Billing, Doctor's Office, Flu Shot, HMO, Medicare, Pap smears, Pneumo, Vaccinations, Well woman exam