In 2011, the Centers for Medicare and Medicaid (CMS) unveiled a new benefit to address the need for annual care for seniors. It was widely hailed as a wonderful thing for Medicare patients who previously had no preventive care unless they paid out-of-pocket for a “complete physical.” What some people overlook is that the new Medicare benefit includes no actual physical examination of any kind.
Posts Tagged HCPCS
There is no one, and I do mean no one, in your medical practice who does not need to know the basics of coding. Here is why:
- Providing services to patients is the business of healthcare. Every person who relies on healthcare for their living should understand something about the business they are in. This should not outweigh the fact that we are privileged to care for patients, but as the saying goes “No money, no mission.”
- It takes a team to produce care. The silos of front desk, billing, nursing and scheduling must come together to share their knowledge and produce a high-quality, reimbursable patient visit. Here are the roles each member of the team plays:
- The patient calls for an appointment and the scheduler matches the patient’s problem to an appropriate appointment type. The scheduler finds out if the patient is new or established and what the patient’s appointment is for.
- The patient arrives for the appointment and the front desk assures that all current demographic and insurance information is collected.
- The nurse rooms the patient, taking vitals, reviewing medications and reviewing the reason for the visit – the chief complaint.
- The physician or mid-level provider cares for the patient, documenting the visit and choosing the appropriate service and diagnosis codes.
- The patient completes the visit by paying any deductibles or co-insurance due and making any future appointments needed. The checkout staff enters the payments and/or charges if the service codes have not already been posted via the EMR.
- The biller “scrubs” the claim, checking for any errors and electronically submits the claim to the payer. The hope is that the claim is clean and will be accepted and paid immediately (within 30 days.)
When staff understands how important their contribution is to the financial viability of the practice and how all the pieces fit together, they are more incentivized to perform.
The death of Google’s Personal Health Record (PHR) should be a wake up call to everyone about electronic medical records (EMR) – it’s not a walk in the park!
Granted, the fact that EMR is very complex software is not the only reason Google Health couldn’t hack it. Many fine articles and blogs point to under-marketing, an unrealistic reliance on consumers to enter data to complete their own records, unusually slow adoption by consumers, and a possibly unrealistic revenue model (selling data.) I’m pretty sure the readers of Manage My Practice could have predicted most of that, especially the part where consumers are not incentivized to enter their own health information.
Here’s my advice to anyone who wants to capture the health data market:
- Any personal health record must be connected to my primary care provider. I don’t want my PHR to be freestanding from my PCP’s (primary care physician/provider) EMR. Really wasteful.
- I want someone I know and trust – maybe someone associated with my PCP – to show me how to use and understand the information in my PHR.
- I want all my other physicians and test centers to automatically send my records to my PHR and for it to load without my participation.
For flu shot updates for the 2011-2012 influenza season, click here.
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)
- 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.
- Q2035 (locally priced)
For additional information on providing the flu shot, see my previous post here.
Steps to digging under the meaning of EMR certification:
- Click to see the most recent alphabetical list (by product name not company) of all products certified here.
- Find the company or companies you are using or are considering using.
- Check that the exact name of the product is what you have or might purchase.
- Check to find out if a module or part of the product is certified or if the complete product is certified.
- Check to make sure the version of the product is the version you have or will have.
If you have questions about each company’s exact criteria met, you are in luck! On the ONC site here, you can click on each company’s detail (“View Criteria”) on the far right column labeled “Certification Status” to see what they have and don’t have. Compare this to how you are anticipating using your EMR to meet meaningful use. The more check marks a company has, the better-equipped they are (and more flexible) to meet your practice needs and to qualify for the stimulus money.
The ONC site with the Certified Health IT Product List (CHPL) is Version 1.0. Version 2.0 is now being developed and will provide the Clinical Quality Measures each product was tested on, and the capability to query and sort the data for viewing. The next version will also provide the reporting number that will be accepted by CMS for purposes of attestation under the EHR (“meaningful use”) incentives programs.
You can tell ONC what you think would be helpful in the new version by emailing your ideas to ONC.email@example.com, with “CHPL” in the subject line.
If you’d like a list of just outpatient/medical practice EMR products or just inpatient / hospital products, I’ve split the big list into two smaller printable lists here:
Tips On Buying An EMR
Remember that meeting meaningful use does not tell the whole story – if you are shopping for an EMR be prepared to go beyond a product’s certification status to consider:
- Flexibility – does it make the practice conform to it or can it conform to the practice? How?
- Templates and best practices – are you starting from scratch in developing protocols, templates and cheat sheets for your practice, or does it have a storehouse of examples to choose from or tweak?
- Built for the physician, or the billing office, or the nurses, but doesn’t really meet the needs of all three? Make sure the functionality is not too skewed to one user group, but if it is, it should be somewhat skewed to the provider.
- Interface and integration with your practice management system. Does the information flow both ways? Do you ever have to re-enter information because one side doesn’t speak to the other?
- Interface with other inside and outside systems: Labs, imaging, hospital systems, ambulatory surgical center systems?
- Built-in Resources: annual upgrade of HCPCS and ICD codes, drug compendium (Epocrates), comparative effectiveness prompting?
- Mobile applications – EMR on your providers’ phones?
- Data entry systems – laptops, notebooks, tablets, iPads, smartphones, voice recognition?
- Hosting – in your office? at the hospital? at the vendor’s data center? in the cloud of your choice?
- What’s the plan for ICD-10? Will they provide practice support and education for the change or will they just change the number of characters in the diagnosis code field?
- Price, including annual maintenance and additional costs for training, implementation, on-site support during go-live, and additional licenses for providers or staff.
Update posted 8-14-2012: For flu shot updates for the 2012-2013 influenza season, click here.
Update posted 9-22-2011: For flu shot updates for the 2011-2012 influenza season, click here.
Update Posted 12-20-2010 – Medicare posted code changes for flu vaccines billed to Medicare after January 1, 2011. Click here for the changes.
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.
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:
- The vaccine is ordered in the spring, with everyone trying hard to guess correctly how many patients will want flu shots in 6 months.
- 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.
- 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.)
- 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?
- 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.
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:
V06.6 Pneumococcus and Influenza (both vaccines at one visit)
- 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.
Here’s your pop quiz:
The NCCI edits are:
A. pairs of services that should not be billed by the same physician for the same patient on the same day.
B. definition refinements for HCPCS codes.
C. diagnosis codes (ICD-9) that cannot be billed together on a CMS 1500 claim.
The answer is below the picture.
If you answered “A”, you’re on top of your game! The King of the National Correct Coding Initiative (NCCI) quarterly analysis is Mr. Frank Cohen and he provides that analysis free of charge for all. Thank you, Frank! With his analysis, you have the opportunity to see what’s changed and what’s new, to tweak your system to catch the pairs, and to make sure you are providing the right care at the right time as well as maximizing your reimbursement.
The Cohen Report:
In summary, there are 16,843 new edit pairs, bringing the total number of active edit pairs to 653,718. Six of these are backdated to an effective date of January 1, 2010. The majority of these (75.17%) are associated to the edit policy “Misuse of column two code with column one code” with 12.82% associated to “Standard preparation / monitoring services for anesthesia”. There are 6,042 unique Column 1 codes and 274 unique Column 2 Codes within the new edits.
I have posted my analysis worksheets for those interested in the details. Go to www.frankcohen.com and click on the Download tab.ï»¿