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Vaccines are a high-volume service in most primary care practices, but are physicians capturing all of the Medicare revenue they’re entitled to?
Not always, says Yvonne Dailey, CPC, CPC-I, CEO of Dailey Billing Services Inc. in Toms River, N.J. Physicians often don’t report the correct codes, or they forget to report certain codes. During peak flu and pneumonia season, these mistakes can definitely add up, she adds.
Dailey provides five tips to help practices bill Medicare Part B correctly.
Know what Medicare Part B covers
Medicare Part B only covers the following immunizations:
Report two codes-
When billing Medicare, physicians frequently omit the code for the administration, says Dailey. This is how practices lose revenue, she explains, adding that the omission of a single administration code could cost the practice approximately $20-$25, depending on the Medicare Administrative Contractor.
“You need to review your denials and make sure the right codes were used before you assume it was a contractual write-off,” Dailey says.
Another mistake is that physicians report a CPT code for the administration rather than a HCPCS code, Dailey says. If the EHR auto-posts a CPT code for all immunizations, physicians will receive a denial when administering vaccines that would normally be covered for Medicare patients.
Best practice is to review each administration code manually or create payer-specific rules within the EHR for Medicare versus commercial payers, says Dailey.
The specific drug, dosage, and route of injection will determine the vaccine code that’s reported in addition to the administration code, says Dailey.
Consider the following:
For the influenza vaccine, report one of the following CPT codes: 90630, 90653-90658, 90660-90662, 90672-90674, 90682, 90685-90688, 90756, or Q2034-Q2039. Payment for these codes range from approximately $9 to approximately $55.
For the hepatitis B vaccine, report one of the following CPT codes: 90739-90740, 90743-90744, or 90746-90747. Payment for these codes range from approximately $26 to approximately $131.
For the pneumococcal vaccine, report one of the following CPT codes:
Medicare also posts updated payment information specifically for the influenza vaccine, so be sure to stay up-to-date.
Don’t forget to report ICD-10-CM diagnosis code Z23
If the sole purpose of the encounter is to administer a vaccine, report Z23 with both the administration and vaccine codes, says Dailey.
However, in many cases, vaccines are given during a visit in which physicians render other services. For example, physicians frequently administer the influenza vaccine (split virus for intramuscular use) during an initial wellness exam.
Report the following codes for this scenario:
Use caution when providing the vaccine for TDAP
Medicare Part B covers the TDAP vaccine only when it’s related to a current injury (e.g., accidental puncture wound), says Dailey.
When a patient with a current injury requires the vaccine, physicians must report a diagnosis code from Chapter 19 of the ICD-10-CM manual for the injury rather than Z23, she adds. The last character in the diagnosis code should be ‘A’ to denote an initial encounter (i.e., current injury) rather than a ‘D’ for subsequent encounter or ‘S’ for sequela.
Also be sure to document the type of injury, how and where it occurred, and the area of the body where the injury was sustained, she adds.
Also note that unlike other vaccines, TDAP administration requires one or more CPT codes-not a HCPCS code-depending on how many separate vaccines are administered.
Create rules within the EHR
For example, some EHRs allow physicians to create rules that prevent them from giving a vaccine before it’s due or remind them when one is due, says Dailey. Rules can also specify that Z23 is automatically reported with every vaccine and administration code, she adds.
Know what to do if Medicare won’t pay
If Medicare Part B doesn’t cover a certain vaccine, providers can bill the patient-but only if they have a signed Advanced Beneficiary Notice (ABN) on file, says David Glaser, JD, attorney at Fredrikson & Byron PA, a business law firm in Minneapolis, Minn.
The ABN must describe the specific service that Medicare won’t cover, why it isn’t covered, and the anticipated amount the patient will owe, he adds.
“You basically need to know in advance why you’re going to get a denial,” says Glaser. “You can’t just get a blanket ABN for every vaccine.”
He provides this example: A Medicare patient presents for a hepatitis B vaccine as a preventive measure. Medicare Part B only covers this vaccine when it relates to a current injury. If the patient insists on receiving the shot even though it’s not covered, the provider should obtain an ABN stating the patient accepts financial responsibility for the vaccine.
The same is true for an influenza vaccine given more than once during the same flu season or a second pneumococcal vaccine given within one year of the initial vaccine.
Something else to keep in mind is that Medicare Advantage plans may cover vaccines not covered under Medicare Part B as long as the vaccine is reasonable and necessary to prevent illness, says Dailey.
For example, a patient with a Medicare Advantage plan requests the hepatitis B vaccine as a preventive measure. Although Part B won’t cover the vaccine in this instance, Part D may.
To learn more about Part D coverage for vaccines, view MLN Fact Sheet ‘Medicare Part D Vaccines and Vaccine Administration’ dated January 2018. To learn whether a specific Part D plan covers a particular vaccine, visit https://www.medicare.gov/find-a-plan/questions/search-by-plan-name-or-plan-id.aspx.