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Everything you need to know about billing for the flu shot this season, including CPT and HCPCS codes by brand and dosage, and the appropriate administration and diagnosis codes.
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FALL 2013 & WINTER 2014
ALL ABOUTBILLING FOR FLU
SHOTSMary Pat Whaley, FACMPE, CPC
President, ManageMyPractice.com(919) 370-0504
WHAT IS THE FLU?
Influenza, also called the "flu," is a contagious respiratory illness caused by influenza viruses. There are over 200,000 hospitalizations from influenza annually. An average of 36,000 Americans die annually due to influenza and its complications – most are people 65 years of age and over. The best way to prevent the flu is to get vaccinated each year during the fall season.
WHO SHOULD BE VACCINATED?
THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) RECOMMENDS UNIVERSAL SEASONAL FLU VACCINATION FOR ANYONE AGE 6 MONTHS AND OLDER.
“THE MAJORITY OF THE 150+ CHILDREN WHO DIES LAST YEAR FROM THE FLU IN THIS COUNTRY
WERE NOT VACCINATED. AND ALTHOUGH IT’S TRUE THAT THE VACCINE DOESN’T PROTECT 100%
OF THOSE WHO GET IT, IT DOES PROTECT MOST FROM LIFE-THREATENING ILLNESS.”
DR. WENDY SUE SWANSON, “SEATTLE MAMA DOC”
FOR MORE FROM SEATTLE MAMA DOC, CLICK HERE
Age 6 months through 4 years (59 months)
Age >50 years with chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic, hematologic or metabolic disorders (including diabetes mellitus.)
WHO SHOULD BE VACCINATED?
Are or will be pregnant during influenza season
Immunosuppressed (including immunosuppression caused by medications or by human immunodeficiency virus)
WHO SHOULD BE VACCINATED?
Age 6 months through 18 years using long-term aspirin therapy and who might be at risk for experiencing REYE SYNDROME after flu virus infection. Residents of nursing homes and other chronic care American Indian/Alaska Natives Those who are morbidly obese
WHO SHOULD BE VACCINATED?
Healthcare personnel, household contacts and caregivers of children <5 years and >50 years old with particular emphasis on vaccinating contacts of children <6 months, and household contacts and caregivers of persons with medical conditions that puts them at a higher risk for severe complications.
WHO SHOULD BE VACCINATED?
PATIENTS WITH A SEVERE ALLERGY TO EGGS – HOWEVER THERE IS A NEW ADULT-ONLY VACCINE CALLED FLUBLOK FOR THOSE WITH EGG ALLERGY
FEVER OR MODERATE TO SEVERE ILLNESS AT THE TIME OF VACCINATION
HISTORY OF GUILLAIN-BARRE SYNDROME AFTER PREVIOUS FLU VACCINES
PREVIOUS ALLERGIC REACTION TO A FLU SHOT
WHO SHOULD NOT BE VACCINATED?
The flu season extends from September to March. Seasonal flu vaccination should begin as soon as vaccine is available (usually early September) and continue throughout the flu season. Seasonal flu outbreaks can happen as early as October, and seasonal flu activity usually peaks during the winter.
WHEN SHOULD EVERYONE GET
VACCINATED?
Most types of injections, including a vaccine like the flu shot, is billed using two codes:
Part One: A code for the flu vaccine itself, whether it is a liquid to be injected, or a mist that is to be inhaled.
Part Two: A code for The administration of the injection
BILLING FOR FLU SHOTS - BASICS
Some payers do not recognize the value of the administration of any vaccine, and will not pay a separate amount for administration, however, most payers, including Medicare, will reimburse for both the vaccine itself and the administration.
BILLING FOR FLU SHOTS - ADMINISTRATION
INJECTION: 90471 – IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) **NOTE: IF GIVING TWO VACCINES, USE 90471 FOR THE FIRST AND 90472 FOR EACH ADDITIONAL VACCINE ADMINISTRATION.
INTRANASAL: 90473 – IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE; 1 VACCINE (SINGLE OR COMBINATION TOXOID) **NOTE: IF GIVING TWO VACCINES, USE 90473 FOR THE FIRST AND 90474 FOR EACH ADDITIONAL VACCINE ADMINISTRATION.
BILLING FOR FLU SHOTS - ADMINISTRATION
G0008 – IMMUNIZATION ADMINISTRATION FOR MEDICARE ONLY
**NOTE: CHECK WITH MEDICARE REPLACEMENT PLANS TO SEE WHICH ADMINISTRATION AND VACCINE CODE THEY PREFER.
BILLING FOR FLU SHOTS - ADMINISTRATION
NOTE: THERE IS A DIFFERENT CODE USED FOR IMMUNIZATION ADMINISTRATION FOR PATIENTS AGE 18 AND YOUNGER, IF THE PROVIDER COUNSELS THE PATIENT/FAMILY ON THE VACCINE (SEE CPT CODES 90460 & 90461.) THESE CODES REPLACE THE STANDARD IMMUNIZATION ADMINISTRATION CODES.
BILLING FOR FLU SHOTS - COUNSELING
In previous years there has been a lot of confusion whether insurance plans covered the flu shot and if they did, if the deductible, co-pay or co-insurance was applicable.
This year, things are much easier now that preventive care, including the flu shot, are covered by almost all plans, and no deductible, co-pay or co-insurance applies, courtesy of the AFFORDABLE CARE ACT.
For patients without insurance, most practices price the vaccine and administration at $25 to $45 per flu shot, depending on the cost of the vaccine they are
BILLING FOR FLU SHOTS - COLLECTIONS
For patients with Medicare Part B, the plan will cover one flu shot per flu season in the fall or winter. Medicare patients pay NOTHING for a flu shot if the doctor or other qualified health care provider accepts assignment for giving the shot. Medicare may cover additional seasonal influenza virus vaccinations if medically necessary.
BILLING FOR FLU SHOTS - MEDICARE
The allowances on the following slide are based on 95% of the AWP (average wholesale price) and do not apply to flu shots furnished in a hospital outpatient department, a Rural Health Clinic (RHC), or a Federally Qualified Health Center (FQHC) for which payment is based on reasonable cost.
BILLING FOR FLU SHOTS - ALLOWABLES
CPT/HCPCS Brand Medicare Allowable90654 Fluzone 18.918
90655 Fluzone 17.243
90656 Afluria, Fluarix, Fluvirin, Fluzone 12.398
90657 Fluzone 6.022
90658 Afluria, FluLavil, Fluvirin, Fluzone
See Q-codes below
90661 Flucelvax 20.663
90662 Fluzone 31.823
90672 FluMist 24.596
90673 FluBlok Pending
90685 Fluzone 23.228
90686 Fluarix, Fluzone 19.409
90687 Pending Pending
90688 FluLaval Pending
Q2033 (M’care) FluBlok Pending
Q2035 (M’care) Afluria 11.543
Q2036 (M’care) FluLaval 8.579
Q2037 (M’care) Fluvirin 14.963
Q2038 (M’care) Fluzone 12.044
Q2039 (M’care) Adult, not otherwise specified Locally determined
BILLING FOR FLU SHOTS – MEDICARE ALLOWABLES
INFLUENZA VACCINE PRODUCTS/CODES FOR THE 2013–2014 INFLUENZA SEASON
For a detailed, printable chart of all available vaccine products with dosages, click on the link below.
BILLING FOR FLU SHOTS – MATCH THE BRAND
Use diagnosis code (ICD-9) V04.81: "Prophylactic vaccination and inoculation against influenza” When giving Pneumococcus and Influenza vaccinations on the same date, use V06.6.
When giving a vaccination at the same time as seeing a patient for a medically necessary office visit, use a modifier 25 on the E/M code and map the E/M to a diagnosis code that describes the reason for the visit.
BILLING FOR FLU SHOTS – DIAGNOSES
GET A FLU SHOT WIDGET LIKE THE ONE BELOWFOR YOUR WEBSITE
FLU SHOT RESOURCES
CLICK HERE TO GO TO THEFLU SHOT/VACCINE FINDER
PHOTO CREDITS
Slide 2: HospitalSlide 3: ToddlerSlide 5: Old Timey ChildSlide 6: Pregnant MomSlide 7: CoupleSlide 8: CaregiverSlide 10: CalendarSlide 11: Syringes
