The Medical Manager’s 2013 Flu Season Update

 

The tweet above was sent out by a very interesting start up named Sickweather on October 19th of last year. Sickweather analyzes data from Twitter and Facebook to determine potential public health concerns by listening to the things people post on social media. If a lot of people are posting about coughing, sneezing or other symptomatic behavior, you could make the assumption that increased disease activity is more likely in the area. The tweet welcoming flu season early was not an ironclad prediction, announcement, or warning but six weeks later the Centers for Disease Control issued a press release titled U.S. Flu Season off to Early Start.”

“The tweet welcoming flu season early was not an ironclad prediction, announcement, or warning but six weeks later the Centers for Disease Control issued a press release titled ‘U.S. Flu Season off to Early Start’.”

The 2012-2013 flu season is shaping up to be  “moderate to severe” with 47 states reporting “widespread geographic influenza activity” to the CDC. Outside of the Pandemic 2009-2010 “Swine Flu” season, the reporting of Influenza Like Illness (or ILI) to care providers this year is at levels we have not seen since 2003-2004. Although reports point to this year’s season being at or near it’s peak, we thought it would be a great time to remind or readers and clients about some of the tools and resources you have at your disposal.

Flu Vaccination 2012

Protecting your Staff

  • If your staff are rusty on basic flu information you can find a wealth of information for providers at the CDC and the Flu.gov websites to catch up on basics and preparation measures.
  • Rule Number One: IF THEY ARE SICK THEY HAVE TO GO HOME. Sick providers and employees are powerless to help patients.
  • A stronger flu season is a good time to review your staffing and preparedness plans both for pandemics specifically and disaster prep in general.

Protecting your Patients

  • If you provide primary care, you are already probably dispensing the most common and effective advice against the flu: vaccination, and prevention, but patients can also be directed to more resources on their own. Tell them to check out of the information available on flu shots and staying healthy at Flu.gov for further research.
  • Remember who is most susceptible to flu-based fatalities and hospitalizations: the young, the elderly, and the already sick. Make sure your vulnerable patients get the information they need up front. If you don’t offer flu shots at your facility, make sure they can find somewhere that does close by.

Protecting Your Revenue Cycle

  • Make sure your billing and coding departments are up on this years Flu Shot billing codes.
  • With the 1st of the year having already rolled over, many of your patients will have new calendar-year deductibles, co-pays and other patient responsibilities. If you haven’t already, maybe now is the time to start a Credit Card on File Program – and we’d love to help!

What other ways do you “flu-proof” your practice each year? Tell us your tips in the comments below!




Providing and Billing for the Flu Vaccine: Guidance from CMS, the CDC and the Affordable Care Act

Update posted 8-14-2012: For flu shot updates for the 2012-2013 influenza season, click here.

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Update posted 9-22-2011: For flu shot updates for the 2011-2012 influenza season, click here.

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Update Posted 12-20-2010 – Medicare posted code changes for flu vaccines billed to Medicare after January 1, 2011.  Click here for the changes.

For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.

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It’s that time again, and despite delayed deliveries to some hospitals and practices, the word on the street is that there will be enough flu vaccine (171 million doses) this year for all who want a flu shot.

Model of Influenza Virus from NIH

Image via Wikipedia

The Center for Disease Control (CDC) recommends that everyone 6 months and older get a flu shot.  Each year’s flu vaccine cocktail is unique and this season’s (2010-2011) flu vaccine will protect against three different flu viruses: an H3N2 virus, an influenza B virus and the H1N1 virus that caused so much illness last season.

The Affordable Care Act and the Influenza Vaccine

Just in time for flu season is the Affordable Care Act’s emphasis on preventive care.  The ACA states:

This influenza season, children 6 months through 18 years, certain high-risk adults 19 through 49 years, and adults 50 years and older who are enrolled in new group and individual health plans will be eligible to receive the seasonal flu vaccine without cost-sharing when provided by an in-network provider.  Beginning in the plan year that starts after March 2, 2011, all adults 19-49 years of age will be eligible to receive the seasonal flu vaccine with no cost-sharing requirements when provided by an in-network provider.

This is great news for the patient and for healthcare in general.  You may consider it good news or bad news, depending on your view of the whole flu shot process.  Here’s how it works in many practices:

  1. The vaccine is ordered in the spring, with everyone trying hard to guess correctly how many patients will want flu shots in 6 months.
  2. The vaccine arrives in the fall and the first hurdle is pricing it, as you will have to decide how much to mark it up to cover the cost of the ordering, handling and stocking and possibly a teeny profit.
  3. The administration of the vaccine also has to be priced to cover the cost of supplies (syringe, alcohol swab, sometimes a bandaid, printed Vaccine Administration Sheets) and the cost of labor (assessing the patient to make sure they can get the flu shot, giving the shot, and documenting the lot numbers in case of a recall.)
  4. The next decision is disbursement.  Do you have a flu shot clinic and have people get in line for the flu shot, or do you take flu shot appointments, do you give flu shots during regular appointments, or some combination thereof? What about drive-through flu clinics?  Do people sit in the parking lot for 15 minutes to make sure there are no bad after-effects?  How do you let patients know about your flu shot plans without costly postcards or advertisements?
  5. Then, there is policy setting for patients whose insurance covers the flu shot and for patients whose insurance does not.  Do you collect and refund if necessary, or do you not collect and bill the patient after insurance responds (Jaws theme music here, please.)

Does Medicare pay for flu shots?

Medicare pays 100% of the allowable for influenza vaccine (and pneumococcal vaccines) and the administration of the vaccines without any out-of-pocket costs to the patient.  One flu vaccine is allowable per flu season, but Medicare will pay for a second flu shot if a physician determines and documents the medical necessity.  A physician’s order is not necessary and a physician’s supervision is not necessary – that’s why patients are able to get a flu shot at the drugstore.  A patient can receive a flu shot twice in one calendar year by getting a flu shot late in one season and getting a flu shot early in the next season.

How should a provider that is not enrolled in Medicare bill for the flu vaccine?

CMS typically does not allow non-enrolled providers to treat Medicare beneficiaries, however, CMS is allowing them to give flu shots this year.  Beneficiaries can receive a flu vaccine from any licensed physician or provider. However, the billing procedure will vary depending on whether the physician or provider is enrolled in the Medicare Program.

If you are not a Medicare-enrolled physician or provider who gives a flu vaccine to a Medicare beneficiary, you can ask the beneficiary for payment at the time of service. The beneficiary can then request Medicare reimbursement. Medicare reimbursement will be approximately $18 for each flu vaccine.

Public health poster from Spanish flu era.
Image via Wikipedia

To request reimbursement, the beneficiary will need to obtain and complete form CMS 1490S.  So the beneficiary may receive reimbursement, you will need to provide the beneficiary with a receipt for the flu vaccine that has the following information written or printed on it:
”¢    The doctor’s or provider’s name and address
”¢    Service provided (“flu vaccine”)
”¢    Date flu vaccine received
”¢    Amount paid

What codes are used for flu shots?

For flu vaccine and vaccine administration, the following codes are used.

Effective September 1, 2009, (no 2010 changes have been announced) the Medicare Part B payment allowances for influenza vaccines are as follows:

  • For HCPCS 90655, the payment will be  $15.447:  Influenza virus vaccine, split virus, preservative free, for children 6- 35 months of age, for intramuscular use
  • For HCPCS code 90656, the payment will be  $12.541: Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use
  • For HCPCS code 90657, the payment will be  $15.684:  Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use;
  • For HCPCS code 90658, the payment will be  $11.368:  Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use
  • HCPCS 90660 (FluMist, a nasal influenza vaccine) may be covered if the local Medicare contractor determines its use is medically reasonable and necessary for the beneficiary. When payment is based on 95 percent of the Average Wholesale Price (AWP), the Medicare Part B payment allowance for CPT 90660 is $22.316 (effective September 1, 2009).

G0008 is the Medicare HCPCS for Administration of influenza virus vaccine, including FluMist.  Other payers usually require use of 90465, 90466, 90467, 90468, 90471, 90472, 90473 or 90474 for administration of the vaccine.

The associated ICD-9 codes for flu shots are:

V04.81    Influenza
V06.6      Pneumococcus and Influenza (both vaccines at one visit)

Other resources:

  • Get your practice and your staff ready for flu season by following the guidelines I write about here.
  • Free downloads from the CDC here.
  • MedLine Plus Articles, Downloads and Resources here
  • Article: Mandating Influenza Vaccine – One Hospital’s Experience (MedScape free account required)
  • National Foundation for Infectious Diseases: Influenza
  • National Influenza Vaccine Summit: Prevent Influenza
  • Vaccine Education Center at Children’s Hospital of Philadelphia (CHOP) -Influenza: What You Should Know (pdf)   EnglishSpanish
  • Medicare Preventive Services Quick Reference Information Chart: Medicare Part B Immunization Billing (Influenza, Pneumococcal, and Hepatitis B) is available here (pdf.)
  • For information on roster billing (billing for many patients at one time) see the Medicare Claims Processing Manual for Preventive and Screening Services (Chapter 18) here (pdf) Section 10-3.

NOTE: Beneficiaries have been advised to contact the Inspector General hotline at 1-800-HHS-TIPS (1-800-447-8477) to file a complaint if they believe their physician or provider charged an unfair amount for a flu vaccine.

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