The medical assistant will see you now

A few weeks ago, a colleague gave me an interesting dilemma. One of her providers, a pediatrician, wanted to bill a 99212 with vaccines even when the patient did not see the doctor. Since the medical assistants spent some time counseling the patient, the doctor wanted to make sure the practice was paid for that time. My colleague’s question was whether or not a 99212 would be acceptable to report to the insurance company in that manner. 

Well, short story shorter, the only office visit we can bill when the provider does not see the patient is a 99211. E&M University has an excellent breakdown of the requirements for each of the codes. 

The requirements for a 99212 include a problem focused history, a problem focused exam, and straightforward medical decision making. While the MA’s can take the history, the only person medically qualified to do an exam or any medical decision making is a provider. And counseling only does not include an exam or any decision making. 

The requirements for a 99211 are incredibly broad. In fact, there are no specific requirements. Anything the patient comes in for that does not require the presence of the physician can be a 99211. Blood pressure checks, ear lavages, EKGs, vaccinations, that sort of thing. 

However, the office does deserve to be reimbursed for any time spent counseling. For pediatricians, there is a code that includes the administration of vaccines and the time spent counseling the patient/guardian. You would use code 90460 for the first vaccine and 90461 for any subsequent vaccines. These codes are also nice because they do not specify the method of administration. You can use 90460 and 90461 for vaccines administered intramuscularly, nasally, or orally.  

If the vaccine is administered with no counseling, you would use the regular 90471 and 90472 codes for your intramuscular administrations.  

As an additional consideration, the 99212 gets paid a very small amount anyway. Probably less than $35.00. AND a copay gets applied that you’ll most likely end up waiving anyway. Getting your provider paid for at least the 90460 and one 90461 will be a higher reimbursement than billing with an incorrect code. And it is my job to make sure that I get my providers the highest reimbursement possible. 

As always, if you have any questions or any clarifications, send me an email at newgenerationbilling@gmail.com. 

96372 for Inpatient Injections

This one is quick and short.

I have been getting a lot of email questions about whether or not 96372 can be used for inpatient billing. Here is the exact text of the description of 96372 from the CPT book:

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

The description itself does not specify a location, so I have billed it for many different settings, and I have never had a problem. Here are the notes included with the description

Do not report 96372 for injections given without direct physician or other qualified health care professional supervision. To report, use 99211. Hospitals may report 96372 when the physician or other qualified health care professional is not present.

Happy holidays!

 

 

Medicare and Immunizations

Medicare routinely pays for two immunizations and will pay for two others under specific circumstances. Specifically, they will pay for influenza and pneumococcal as preventive, and Medicare will pay for the tetanus and hepatitis B vaccines in certain cases with medical necessity. Read on.

The new Medicare flu codes have been around for a while,  but we recently ran into a few offices in 2012 who told us they have been having a hard time getting paid for their flu shots from Medicare. Long story short, they were using the wrong substance AND administration codes. And since Medicare will pay  just under $30 for the administration of the injection and $7-$15 for the substance itself, missing out on those can turn into a loss of hundreds of dollars per year. So, lets fix that, shall we?

All of our posts are going to follow the same format; we are going to first explain the important bits, and then we give you the charts and links that we personally use and distribute to our customers. So remember to bookmark us or add us to your favorites, because here you can keep all of your invaluable tools in one place.

The CPT codes for Medicare to bill the flu shot break down by the brand the doctor purchases. If you’re at the office, take a look in the fridge, but if you are at a billing service, you need to please call your office manager and get that information. The reimbursement varies significantly depending on the code, and we can get our providers audited if we just make that decision ourselves. Medicare uses codes Q2034–Q2038, and here is the specific breakdown.

Brand         CPT

Agriflu      Q2034
Afluria      Q2035
FluLaval   Q2036
Fluvirin     Q2037
Fluzone    Q2039

Remember to bill the G0008 administration code along with the vaccine. The Q-code is only for the substance. It is the G-code that we bill for the actual service–the process of injecting the immunization into a patient’s–ahem–hip. If the patient is ONLY seen for the flu shot, then you would simply bill those two codes. If the patient had an exam on the same visit you can bill an E&M code as well and Medicare will pay them all separately without any modifiers necessary. Just remember to put your V04.81 (ICD10 Z23) diagnosis primary on the Q-code and the G-code and your medical diagnosis on the E&M. Please remember, these codes are just for Medicare. For the rest of your private insurances, you still use the 90658 for the substance and the 90471 or 90472 for the admin.

The pneumo, Hep B, and the tetanus are a little bit easier.

For the pneumococcal, you bill with the diagnosis of V03.82 (ICD10 Z23) and the CPT code 90732. Use G0009 for the administration. Easy.

Medicare will pay for the tetanus immunization, however, they will not pay it as a preventive service. Patients who come in with wounds (ICD9 codes 860.xx0-894.xx and ICD10 codes S00-T14) are eligible for reimbursement on the tetanus vaccine. Remember to use the wound diagnosis primary and the V03.7 (ICD10 Z23), tetanus toxoid alone, as secondary. The tetanus can be billed with 90471 as the administration.

For hep B, Medicare will only pay for the immunization series for patients they consider as “high risk.” A high risk patient is one with renal disease, or hemophilia, or a client of institutions for the mentally handicapped.

A word of caution: Medicare has VERY strict rules regarding the frequency of these immunizations. The flu and the pneumo vaccines can be administered once per year. If 365 days have not passed since the last immunization you WILL NOT be paid. No amount of appealing will change this. Please, make it clear with your front desk, your MA’s, and most importantly, with your doctors, that we need to check the date of the last immunization for our established patients BEFORE administering the vaccine.

Here are your tools:

• For starters, we reference this handy-dandy chart for all of our customers that breaks down the Medicare flu shot codes. Print it out, stick it on your wall. That’s what I did.
• This is a link directly to the CMS Medicare site with all the information you could ever want regarding their immunization policies.

If this doesn’t answer all of your questions, call us at (909) 374-5439 and ask for Heather. Or you can email us at newgenerationbilling@gmail.com.