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!




CMS Releases Pricing and Codes for 2011 – 2012 Flu Vaccine Given After September 1, 2011

NOTE: The 2012 – 2013 flu shot codes can be found here.

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Today the Centers for Medicare and Medicaid Services (CMS) released the new pricing for flu shots for Medicare patients for the 2011-2012 flu season. The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95% of the Average Wholesale Price (AWP) as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department.  When the vaccine is furnished in the hospital outpatient department, payment for the vaccine is based on reasonable cost.

What do Medicare patients have to pay for the flu shot?

Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations.  All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine. Do not collect from Medicare patients for the vaccine or the administration of a flu shot.

What will Medicare pay for the flu shot?

The payment allowances below reflect the annually updated payment allowance for the listed CPT codes and Q-codes when the vaccines are furnished outside the hospital outpatient department.

Allowables Effective for Dates of Service between September 1, 2011 and August 31, 2012

CPT 90654: $18.383
CPT 90655: $15.705
CPT 90656: $12.375
CPT 90657: $6.653
CPT 90660: $22.316
CPT 90662: $30.923

Q2035 (Afluria): $11.543
Q2036 (Flulaval): locally priced
Q2037 (Fluvirin): $13.652
Q2038 (Fluzone): $13.306
Q2039 (N.O.S.): locally priced

How should the flu shot be coded?

  1. Choose the Q code or CPT code that is appropriate for the brand of vaccine you are giving or the special circumstances (pediatric dose, regular dose, high dose, preservative free, etc.)
  2. Use the Administration Code G0008
  3. Use the Diagnosis Code: V04.81

Choose one code for the vaccine:

90655 – Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use

90656 – Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use

90657 – Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use

90660 – Influenza virus vaccine, live, for intranasal use

90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

Q2035 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)

Q2036 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)

Q2037 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirun)

Q2038 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)

Q2039 – Influenza virus vaccine, split virus, when administered to individuals3 years of age and older, for intramuscular use (Not Otherwise Specified)

 

How many flu shots will Medicare pay for?

Medicare will pay for one flu shot per influenza season in the fall or winter. Medicare may cover additional seasonal influenza virus vaccinations if medically necessary.

 

What is different if the patient gets the flu shot somewhere besides the physician’s office?

Institutional Providers: Additional Billing Information

Hospitals, other than Indian Health Service (IHS) Hospitals
and Critical Access Hospitals (CAHs) 12X, 13X
CAHs: Method I and II and IHS CAHs 85X
IHS Hospitals 12X, 13X
Skilled Nursing Facilities (SNFs) 22X, 23X
Home Health Agencies (HHAs) 34X
Comprehensive Outpatient Rehabilitation Facilities (CORFs) 75X

Revenue Codes: 0636 – vaccine
0771 – administration

Rural Health Clinics (RHCs) 71X

Federally Qualified Health Centers (FQHCs) – 77X (for dates of service on or after April 1, 2010)

Do providers that only provide immunizations need to enroll in the Medicare Program?

Yes. Providers must enroll in the Medicare Program even if immunizations are the only service they will provide to beneficiaries. They should enroll as provider specialty type 73, Mass Immunization Roster Biller, by completing Form CMS-855I for individuals or Form CMS-855B for a group.

Click here to locate these forms.

What is a mass immunizer?

A mass immunizer offers seasonal influenza virus and/or pneumococcal vaccinations to a large number of individuals and may be a traditional Medicare provider or supplier or a nontraditional provider or supplier (such as a senior citizens’ center, a public health clinic, or a community pharmacy). Mass immunizers must submit claims for immunizations on roster bills and must take assignment on both the vaccine and its
administration. A mass immunizer should enroll with the Medicare Contractor prior to influenza season.

What is Roster Billing?

(Influenza & Pneumococcal Vaccinations Only)

The simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass PPV and influenza virus vaccination programs. (Medicare has not developed roster billing for hepatitis B or other vaccinations.) Roster billing can also substantially lessen the administrative burden on physician practices by allowing them to submit one claim for all of the Medicare beneficiaries that received either the PPV or influenza vaccine on a given day. Medicare will often refer to these providers, who utilize roster billing, as “Mass Immunizers.”

For Medicare Part B submission, physician practices and other “Mass Immunizers” must submit a separate pre-printed CMS-1500 paper claim form or bill electronically for each type of vaccination (either influenza or PPV) and attach a roster list containing information for 2 or more Medicare beneficiaries. When “mass immunizers” choose to conduct roster billing electronically, they are required to use the HIPAA-adopted ASC X12N 837 claim standard. Local Medicare Carriers may offer low or no-cost software to help providers utilize roster billing electronically, however, this software is not currently available nationwide so check with your local carrier for specifics in your area.

All entities that submit claims on roster bills must accept assignment.

Roster bills submitted by providers to a Medicare carrier must contain more than one patient and the date of service for each vaccination administered must be the same. (Medicare policy was changed July 1, 1998, and the requirement that a minimum of five beneficiaries be vaccinated per day in order to roster bill was reduced to two beneficiaries per day.)

To further minimize the administrative burden of roster billing, the following blocks can be preprinted on a CMS-1500:

Block 1: Medicare
Block 2: See Attached Roster
Block 11: None
Block 20: No

Block 21: V04.81 for influenza or V03.82 for pneumococcal
Block 24B: ALL entities should use POS code “60” for roster billing. (POS code “60” = Mass
Immunization Center.)

Block 24D: Use appropriate vaccine and administration codes (separate line items for each)

Block 24E: Use “1” for lines 1 and 2
Block 24F: Use the unit cost of the particular vaccine (Contractors will replicate the claim for
each beneficiary listed on the roster.)
Block 27: Yes
Block 29: $0.00
Block 31: Signature
Block 32: Enter the name, address and zip code of the location where service was provided
Block 32a: NPI of the service facility
Block 33: Provider Identification Number or NPI when required
Block 33a: NPI of the billing provider or group

A separate CMS-1500 for each type of vaccination must have an attached roster that includes the
following information:
• Patient Name and Address
• Health Insurance Claim Number
• Date of Birth
• Sex
• Date of Service
• Provider’s Name and Identification Number
• Signature or stamped “Signature on File”
• Control number for the contractor

A “signature on file stamp” or notation qualifies as a signature on a roster claim form in cases where the provider has access to a signature on file in the beneficiary’s record (e.g., when the vaccine is administered in a physician’s office).

The format of the beneficiary roster can be modified to meet the needs of individual providers. It is the responsibility of the carrier to develop suitable roster formats that meet provider and carrier needs and contain the minimum data necessary to satisfy claims processing requirements for these claims.




Medicare Releases New Product-Specific HCPCS Codes for Flu Shots Billed After January 1, 2011

NOTE: The 2012 – 2013 flu shot codes can be found here.

For flu shot updates for the 2011-2012 influenza season, click here.

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Changes in Flu Shot Codes When Billing On/After January 1, 2011

CMS has created specific HCPCS codes and payment allowances to replace CPT code 90658 for Medicare billing purposes for the 2010-2011 influenza season. Note that these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized.

    • Q2035 (locally priced)
      • Afluria vacc, 3 yrs & >, im
      • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
    • Q2036 ($7.439 national allowable)
      • Flulaval vacc, 3 yrs & >, im
      • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
    • Q2037 ($13.253  national allowable)
      • Fluvirin vacc, 3 yrs & >,im
      • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
    • Q2038 ($12.593  national allowable)
      • Fluzone vacc, 3 yrs & >, im
      • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
    • Q2039 (locally priced)
      • NOS flu vacc, 3 yrs & >, im
        • Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)

      Other information:

      • For dates of service between October 1, 2010 and December 31, 2010, the CPT 90658 and the Q-codes will be valid for billing; however, providers may not bill Medicare for both the CPT 90658 and any of the Q-codes for the same patient for the same date of service. Thus, if a provider vaccinates a beneficiary on any date between October 1, 2010 and December 31, 2010, the provider may either bill Medicare immediately using CPT 90658, or hold the claim and wait until January 1, 2011 to bill Medicare using the most appropriate Q-code. If a claim has already been submitted and processed using CPT 90658, then there is no need to use the Q-code for that same service.  For dates of service on or after January 1, 2011, providers may only bill Medicare for one of the HCPCS codes that appropriately describes the specific vaccine product administered.
      • For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.
      • Annual Part B deductible and coinsurance amounts do not apply to these vaccines.  All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.
      • Be aware that Medicare contractors will not search their files to adjust payment on claims paid incorrectly prior to implementing CR7324. However, they will adjust such claims that you bring to their attention.

For additional information on providing the flu shot, see my previous post here.

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