The new winner of my ongoing competition for the CMS Employee Speaker contest is Dr. Daniel Duvall, Medical Officer, Hospital and Ambulatory Policy Group Center for Medicare! During a recent ICD-10 call, Dr. Duvall spoke clearly, was easy to understand and kept my attention.
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.
For additional information on providing the flu shot, see my previous post here.
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.
Image by sxyblkmn via Flickr
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.
There are 36 new terminated edit pairs with 12 backdated to January 1, 2010 and two backdated to April 1, 2010. The edit policies associated to these edit pairs are distributed between “Misuse of column two code with column one code” (44.4%), “CPT Manual and CMS coding manual instructions” (33.3%) and “More extensive procedure” (22.2%).
There were 413 edit pairs with modifier changes. Of these, 387 went from 0 (no modifier permitted) to 1 (modifier permitted) and 26 went from an indicator of 0 to an indicator of 1.
There are currently 1,336 duplicate entries; codes that were activated at one point then terminated and then re-activated. There are 5,318 swapped edit pairs; situations where the edit pair was introduced at one point in a specific order (column 1 and column 2), terminated and then re-activated with the edit pair in the opposite order.
I have posted my analysis worksheets for those interested in the details. Go to www.frankcohen.com and click on the Download tab.ï»¿