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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Announcement From WHO: World Now at the Start of 2009 Influenza Pandemic

Statement to the press by WHO Director-General Dr Margaret Chan
11 June 2009
World now at the start of 2009 influenza pandemic
Dr Margaret Chan
Director-General of the World Health Organization

Ladies and gentlemen,

In late April, WHO announced the emergence of a novel influenza A virus.

This particular H1N1 strain has not circulated previously in humans. The virus is entirely new.

The virus is contagious, spreading easily from one person to another, and from one country to another. As of today, nearly 30,000 confirmed cases have been reported in 74 countries.

This is only part of the picture. With few exceptions, countries with large numbers of cases are those with good surveillance and testing procedures in place.

Spread in several countries can no longer be traced to clearly-defined chains of human-to-human transmission. Further spread is considered inevitable.

I have conferred with leading influenza experts, virologists, and public health officials. In line with procedures set out in the International Health Regulations, I have sought guidance and advice from an Emergency Committee established for this purpose.

On the basis of available evidence, and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met.

I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6.

The world is now at the start of the 2009 influenza pandemic.

We are in the earliest days of the pandemic. The virus is spreading under a close and careful watch.

No previous pandemic has been detected so early or watched so closely, in real-time, right at the very beginning. The world can now reap the benefits of investments, over the last five years, in pandemic preparedness.

We have a head start. This places us in a strong position. But it also creates a demand for advice and reassurance in the midst of limited data and considerable scientific uncertainty.

Thanks to close monitoring, thorough investigations, and frank reporting from countries, we have some early snapshots depicting spread of the virus and the range of illness it can cause.

We know, too, that this early, patchy picture can change very quickly. The virus writes the rules and this one, like all influenza viruses, can change the rules, without rhyme or reason, at any time.

Globally, we have good reason to believe that this pandemic, at least in its early days, will be of moderate severity. As we know from experience, severity can vary, depending on many factors, from one country to another.

On present evidence, the overwhelming majority of patients experience mild symptoms and make a rapid and full recovery, often in the absence of any form of medical treatment.

Worldwide, the number of deaths is small. Each and every one of these deaths is tragic, and we have to brace ourselves to see more. However, we do not expect to see a sudden and dramatic jump in the number of severe or fatal infections.

We know that the novel H1N1 virus preferentially infects younger people. In nearly all areas with large and sustained outbreaks, the majority of cases have occurred in people under the age of 25 years.

In some of these countries, around 2% of cases have developed severe illness, often with very rapid progression to life-threatening pneumonia.

Most cases of severe and fatal infections have been in adults between the ages of 30 and 50 years.

This pattern is significantly different from that seen during epidemics of seasonal influenza, when most deaths occur in frail elderly people.

Many, though not all, severe cases have occurred in people with underlying chronic conditions. Based on limited, preliminary data, conditions most frequently seen include respiratory diseases, notably asthma, cardiovascular disease, diabetes, autoimmune disorders, and obesity.

At the same time, it is important to note that around one third to half of the severe and fatal infections are occurring in previously healthy young and middle-aged people.

Without question, pregnant women are at increased risk of complications. This heightened risk takes on added importance for a virus, like this one, that preferentially infects younger age groups.

Finally, and perhaps of greatest concern, we do not know how this virus will behave under conditions typically found in the developing world. To date, the vast majority of cases have been detected and investigated in comparatively well-off countries.

Let me underscore two of many reasons for this concern. First, more than 99% of maternal deaths, which are a marker of poor quality care during pregnancy and childbirth, occurs in the developing world.

Second, around 85% of the burden of chronic diseases is concentrated in low- and middle-income countries.

Although the pandemic appears to have moderate severity in comparatively well-off countries, it is prudent to anticipate a bleaker picture as the virus spreads to areas with limited resources, poor health care, and a high prevalence of underlying medical problems.

Ladies and gentlemen,

A characteristic feature of pandemics is their rapid spread to all parts of the world. In the previous century, this spread has typically taken around 6 to 9 months, even during times when most international travel was by ship or rail.

Countries should prepare to see cases, or the further spread of cases, in the near future. Countries where outbreaks appear to have peaked should prepare for a second wave of infection.

Guidance on specific protective and precautionary measures has been sent to ministries of health in all countries. Countries with no or only a few cases should remain vigilant.

Countries with widespread transmission should focus on the appropriate management of patients. The testing and investigation of patients should be limited, as such measures are resource intensive and can very quickly strain capacities.

WHO has been in close dialogue with influenza vaccine manufacturers. I understand that production of vaccines for seasonal influenza will be completed soon, and that full capacity will be available to ensure the largest possible supply of pandemic vaccine in the months to come.

Pending the availability of vaccines, several non-pharmaceutical interventions can confer some protection.

WHO continues to recommend no restrictions on travel and no border closures.

Influenza pandemics, whether moderate or severe, are remarkable events because of the almost universal susceptibility of the world’s population to infection.

We are all in this together, and we will all get through this, together.

Thank you.




More Practice Management Resources to Help You Get Your Community Illness Plan in Place

© Cammerayda... | Dreamstime.comNow is the time to follow-up on those good intentions of yours to make sure your swine flu/pandemic illness policy is all that is should be.  Things are calming down a bit (although US numbers are rising, cases are mild) and as we might have a bit of calm before the next storm, it is the ideal time to give yourself a policy and training check-up while the topic is fresh.

  1. Do you have a policy for dealing with a community illness that is more than your typical flu season?
  2. Does your policy include detailed information that most anyone in your organization could follow if you were not able to give directions?
  3. Do you know what the local hospitals’ plans and policies are?
  4. Have you clarified roles for each of your clinical and administrative staff and provided them with detailed information on their responsibilities during a community illness?
  5. Do you understand what your practice is required to do to report information to local, state and national authorities?
  6. Have you located resources for or designed patient education materials appropriate for your population?
  7. Have you integrated community illness information into your new employee orientation and your annual staff training materials?

If you answered “no” or “maybe” to any of the questions above, here are some resource links to help you finalize your plan and get it firmly in place before it’s needed.  Also check my previous article on preparedness here.

News Coverage of the Swine Flu – alltop.com is a feed aggregator and this page on alltop gives you the latest news coverage on swine flu from all the major networks in the world.  Alltop is a fascinating site to investigate; I have a feed from alltop.com on the sidebar of my site that gives you fresh topics on leadership.

This article on the Spare Change blog by Nedra Weinreich is one of the VERY best articles discussing communciating about the flu.

Medscape’s H1N1 Influenza A (Swine Flu) Alert Center is updated frequently to provide the latest news, clinical guidance, commentary, and resources on influenza A (H1N1).  Medscape Today is by WebMD.

How EHRs can be used to track and suppress an infectious disease outbreak such as the Swine Flu by EHR Scope blog.

What’s On the Horizon for a Swine Flu Vaccine by Steve Simmons, MD with Q & A, from the Better Health website.

Facts About Pork Safety and the Flu Outbreak by the National Pork Board

Telephone Triage of Patients With Influenza by Jonathan L. Temte, MD, PhD on the American Academy of Family Physicians website (Excellent triage template!)

Let’s Hold Hands: Why Viruses Love Humans by Meredith F. Small, LiveScience’s Human Nature Columnist

Viral Goes Viral Online, the Pew Research Center reports that Americans tracked news about the fast-moving swine flu virus more closely than any other story last week, with most turning to television for details on its spread. Still, when people were asked to name which information source was most useful, the largest share chose the internet. (How are you providing your patients with fresh information electronically?)

Schools Consider Distance Learning Alternatives to Prepare for Swine Flu Pandemic By Jamie Littlefield, About.com Guide to Distance Learning since 2004 (What about distance medicine (telemedicine, virtual visits) as an alternative to office visits for non-flu patients?)

“Flu Safety Kit” for travelers by minimus.biz.   3 travel-sized products and advice on staying healthy are contained inside of the clear, vinyl  bag with a snap closure. Includes: Clorox Disinfecting Wipes To Go Pack – Fresh Scent, Kleenex® Tissues Pocket Pack and Purell® Hand Sanitizer, 1 oz ($5.77) – (I’m surprised it doesn’t have a mask.)  Tuck in a refrigerator magnet with your practice name and you’ve got a great patient giveaway.