Tag Archives: Immunizations

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

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.

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Filed under Administrations, Billing, CPT, Flu Shot, ICD9, Immunizations, Medical Billing, Medicare, Tetanus