Pulmonology Coding Alert

Due to the shortage of flu vaccinations, some pulmonologists are just receiving their supplies along with the bill. Manufacturing delays postponed delivery as much as two months in some areas. I think its fair to say that things have gone more smoothly in most years in the past, says Steven Black, MD, co-director of the Kaiser Permanente Vaccine Study Center in Oakland, Calif. How do physicians code and set the fee so they can get properly reimbursed for the flu shot? Do patients need to sign a waiver so that if Medicare doesnt cover the cost, they will be responsible?

According to HCFA, every year pneumonia and flu take the lives of 40,000 to 70,000 Americans more than all other vaccine-preventable diseases combined. Some 90 percent of these deaths are in the Medicare population.

Coding for the Vaccination

Code 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid]) and the add-on code 90472 (each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) must be reported in addition to the vaccine and toxoid codes 90476-90749, which identify the vaccine product only.

When coding flu vaccinations, pulmonologists should use the diagnosis code V04.8. To report the proper vaccine product, there are three codes: 90657 (influenza virus vaccine, split virus, 6-35 months dosage, for intra-muscular or jet injection use), 90658 (influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use) and 90659 (influenza virus vaccine, whole virus, for intramuscular or jet injection use). The administration of influenza virus vaccine is G0008 (administration of influenza virus vaccine when no physician fee schedule service on the same day).

For pneumonia, use 90732 (pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for subcutaneous or intramuscular use). Use G0009 (administration of pneumococcal vaccine when no physician fee schedule service on the same day) to code the administration. Diagnosis code V03.82 (need for prophylactic vaccination and inoculation against pneumococcus pneumoniae) is used if the sole purpose for the visit is to receive the vaccine.

When a physician sees a beneficiary for the sole purpose of administering an influenza or pneumonia vaccine, he or she may not routinely bill for an office visit. If a patient receives other services constituting an office visit level of service, however, the physician may bill for a visit and Medicare will pay if it is reasonable and medically necessary.

Keep in mind that G0008 and G0009 may be paid in addition to other services, including evaluation and management (E/M) services and are not subject to bundling. Medicare also will pay twice for the administration fee if a beneficiary receives both the influenza vaccine and the pneumococcal vaccine on the same day.

When billing only for the administration, coders should indicate in block 24 of the HCFA 1500 form that they did not furnish the vaccine. For roster-billed claims, this can be accomplished by lining through the preprinted 24 line item component that was not furnished by the billing entity or individual.

For Medicare, the influenza and pneumonia vaccine benefits do not require any beneficiary coinsurance or deductible. Therefore, a Medicare beneficiary has a right to receive this benefit without incurring any out-of-pocket expense. In addition, the administrating entity is required by law to submit a claim to Medicare on behalf of the beneficiary.

High Costs vs. Average Cost

According to HCFA Program Memorandum B-00-63 (dated Nov. 15, 2000), carriers must disregard the average wholesale price (AWP) of any flu vaccine not available at the time and consider only the AWP of the products that can be purchased. In other words, pulmonologists would recover the average wholesale price based on actual charged costs, not estimates.

Hope Sprague, CPC, an independent coding specialist in Portland, Ore., points out that the memo also states that carriers that processed any claims with a lower price are not required to re-open the claims to correct the price. But any claims brought to your attention may be re-adjudicated at the higher payment allowance. With that in mind, pulmonologists may wish to examine their business processes to determine if they should resubmit claims.

In addition, the January 2001 edition (version 7.0) of the Correct Coding Initiative (CCI) requires all carriers to manually delete the edits associated with G0008 and G0009. If any of these codes is billed with E/M on the same date of the service, HCFA requires a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Pulmonologists should resubmit claims that have been denied for reconsideration, by adjusting to meet this memo.

Medicares Coverage and Reimbursement Policy

For the purpose of Medicares influenza or pneumonia vaccination benefit, any individual or entity meeting state licensure requirements may qualify to have payment made for furnishing and administering the vaccines to Medicare beneficiaries enrolled under Part B, as long as certain Medicare requirements are met. Medicare does not require a physician to be present, but the law in individual states may require a physician order or other physician involvement.

Medicare generally pays for one influenza vaccine per season. This may mean that a beneficiary will receive more than one influenza vaccination in a 12-month period. For example, a beneficiary may receive an influenza vaccination in December 2000 for the 2000/2001 influenza season and another influenza vaccination in October 2001 for the 2001/2002 influenza season. In this case, Medicare will pay for both shots because the beneficiary received only one influenza shot per season. Medicare will pay for more than one influenza vaccination per influenza season if it is reasonable and medically necessary.

High-risk individuals need pneumonia vaccination only once in a lifetime. Revaccination of persons 65 years of age or older who are not at highest risk is not appropriate. If a beneficiary who is not at highest risk is revaccinated because of uncertainty about his or her vaccination status, Medicare will cover the revaccination.

Free or Fee? Payment Depends on Your Practice

Medicare pays 100 percent of the Medicare-approved charge or the submitted charge, whichever is lower. Neither the $100 annual deductible nor the 20 percent coinsurance apply. Therefore, if a beneficiary receives an influenza or pneumonia vaccination from a physician, provider or supplier who agrees to accept assignment (i.e., agrees to accept Medicare payment as payment in full), there is no cost to the beneficiary. If a beneficiary receives the vaccination from a physician, provider or supplier who does not accept assignment, the physician may collect his or her usual charge but may not roster bill for the service. Participating institutional providers and physicians, providers, and suppliers that accept assignment must bill Medicare if they charge a fee to cover any or all costs related to the provision and/or administration of the vaccines. They may not collect payment from beneficiaries.

Nonparticipating physicians, providers and suppliers that do not accept assignment may collect payment from the beneficiary, but they must submit an unassigned claim on the beneficiarys behalf. A physician, provider or supplier may not charge a Medicare beneficiary more for an immunization than he or she charges a non-Medicare patient.

The 5 percent payment reduction for physicians who do not accept assignment does not apply to the influenza and pneumococcal benefit. Only items and services covered under limiting charge are subject to the reduction.

Nongovernmental entities (providers, physicians or suppliers) that provide immunizations free of charge to all patients, regardless of their ability to pay, must also provide the benefit free of charge to Medicare beneficiaries and may not bill Medicare. A nongovernmental entity that does not charge patients who are unable to pay or reduces its charge for patients of limited means (sliding fee scale) but does expect to be paid if a patient has health insurance that covers the items or services provided, may bill Medicare and receive Medicare program payment. The entity may bill Medicare for the amount that is not subsidized from its budget. For example, an entity that incurs a cost of $7.50 per influenza shot and pays $2.50 of the cost from its budget may bill the carrier the $5.00 cost that is not paid out of its budget.

State and local government entities (such as public health clinics) may bill Medicare for immunizations given to beneficiaries even if they provide immunizations free to all patients, regardless of their ability to pay.