Practice Management Alert

There are times you can bill an additional E/M service--we-ll tell you when

Question: Our office is going to have a flu shot clinic for patients. We also administer flu shots and intranasal flu vaccines during appointments. How should I bill for these various vaccines to ensure payment?

As flu season approaches, now's the time to sort out your flu immunization billing. Often offices administer the flu vaccine in just one immunization, but that doesn't mean billing for it is quite that simple. To ensure the claim's success, you need to know what type of influenza vaccine the doctor used with the patient, the patient's age, and the number of injections the doctor gave during the encounter.

Fight potential snafus on flu immunization claims by following these four steps to ensure claims success and proper reimbursement for the influx of flu vaccine services you-re sure to see this season.

Step 1: Figure Out the Vaccine Type

When choosing the proper codes to bill for flu immunizations, you-ll need two codes. The first is the vaccine code. Look at the vaccine label to determine whether you should report 90656 (Influenza virus vaccine, split virus, preservative-free, when administered to 3 years of age and older, for intramuscular use) or 90658 (Influenza virus vaccine, split virus, when administered to 3 years of age and older, for intramuscular use).

Caution: Make sure you-re checking the documentation and labeling for each vaccine. -Know whether you are providing true preservative-free vaccines- before choosing which code to submit, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Don't miss: If the physician or nurse administered the flu vaccine intranasally, don't turn to 90656 or 90658. Instead, bill 90660 (Influenza virus vaccine, live, for intranasal use).

Step 2: Decide on an Admin Code

The next code you-ll need to bill properly for flu vaccinations is the administration code, which tells the payer what work your staff performed. The trick is that you need to bill differently to Medicare and private payers.

If the flu immunization is the primary vaccine that your physician orders or if the patient receives the immunization during a flu shot clinic, bill private carriers with 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]).

Alternative: Sometimes the physician will administer the flu immunization along with another separately injected vaccine. In this case, for a private-insurance patient, you should bill +90472 (- each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) to reflect the second immunization.

If the patient receives an intranasal vaccine, you should bill private payers with 90473 (Immunization administration by intranasal or oral route; one vaccine [single or combination vaccine/toxoid]) or +90474 (... each additional vaccine).

The Medicare difference: If you-re billing Medicare for the flu immunization administration, use G0008 (Administration of influenza virus vaccine) regardless of the vaccine type.

Tip: For flu immunization clinics, be sure to check for any carrier guidelines about billing for groups of patients or patient coverage of public healthcare events (for example, roster billing), says Lori Doll, CPC, billing specialist for The Asthma and Allergy Center in Papillion, Neb.

Step 3: Attach All Applicable Diagnosis Codes

For the diagnosis code, you-ll attach the same diagnosis to both the vaccine and administration codes. The proper diagnosis code for most carriers is V04.81 (Need for prophylactic vaccination against certain viral diseases; other viral diseases; influenza) regardless of the type of encounter.

Tip: Some private insurance carriers -may require not only the V code but also a condition for which the flu shot is strongly encouraged or required,- Pohlig says. The payer may require the ICD-9 for the co-morbid condition (for instance, 493.90, Asthma, unspecified) on the claim form.

Exception: Report V06.6 (Need for prophylactic vaccination and inoculation against streptococcus pneumoniae [pneumococcus] and influenza) on claims you submit when a patient visits your office for both the pneumococcal pneumonia (PPV) and influenza vaccines.

Good advice: Check with your individual carriers to see if they have particular guidelines about reporting flu vaccines. -When you are dealing with multiple payers who require specific billing instructions, be familiar with them,- Doll says.

Step 4: Look for E/M Services

If a patient has an appointment for a flu immunization only or your office is conducting a flu immunization clinic, then your claim should only include codes for the vaccine type and administration. If your physician sees the patient and documents the E/M details and the medical necessity of the visit, be sure that you bill for that E/M service along with the flu immunization codes, Pohlig says.

Modifier help: You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that it is separate from the flu immunization service.

Pointer: Your office can offer flu immunizations to new patients. You do not have to bill a new patient visit for a patient before you perform services for him. But keep in mind that once you give the patient the flu immunization, the patient is an established patient. Therefore, if your physician gives the patient the immunization and then the patient returns for an E/M visit within the next three years, you should bill an established patient office visit (99211-99215) and not a new patient visit.

Beware: Do not bill 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) when the patient only comes in for a flu immunization. You cannot bill 99211 on the same day as a flu immunization, Pohlig says.

Bottom line: -Always check your local carrier's policy before the season, know what CPT codes and diagnosis code to use and what the fee will be for those private-pay patients, and share with your front-desk staff,- Doll says.