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.
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 firstname.lastname@example.org.