Our providers believe they can charge a 99202/99212 along with a flu shot. The patients are scheduled for flu shots only and no other issues are addressed. Is there ever a situation where this is acceptable? What support can I provide the providers?
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Wiki FLU SHOTS
- Thread starter baskiles
- Start date
amyjph
True Blue
This is probably one of the easiest scenarios to find answers for by doing a small amount of research. Are they appending a modifier 25 to the E/M reported with other CPT such as 90471, 90460? If so, did they meet the requirement of a significant, separately identifiable evaluation and management service? If not, they can't. If billing G0008 the code states "Do not report an office visit if the only reason for the visit was to receive a vaccination." If you are talking about a new patient, one might expect to see an E/M for that, it would depend on the documentation of each individual encounter. You would look up preventive and/or vaccine policies for the payer. If your group is routinely doing this with a high volume of claims, they are going to get the attention of the payers.
If a physician sees a beneficiary for the sole purpose of administering one of these vaccines, an office visit cannot be billed. However, if the beneficiary receives other services which constitute an office visit, then one can be billed.
If a physician sees a beneficiary for the sole purpose of administering one of these vaccines, an office visit cannot be billed. However, if the beneficiary receives other services which constitute an office visit, then one can be billed.
- Only if there is a separately identifiable E/M service performed outside of vaccine counseling and immunization administration may a separate E/M visit code be reported, along with modifier 25: Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
CBLENNIE
Expert
According to the FDA's NDC look-up tool the NDC for Fluad Quadrivalent is 70461-123-03 for a carton of 10 syringes or 70461-123-04 for a single syringe:
Also, I found the package insert on the DailyMed National Library of Medicine NIH's website for the 2023-2024 Fluad Quadrivalent (see link) which lists these same 2 NDC codes.
So, if you are purchasing single syringes, you would use 70461-123-04 and if you are purchasing the 10 syringe boxes you would use 70461-123-03.
Thank you so much for taking your time to answer this. All good support information. I totally agree.
Can anyone help with with a FLUAD 11 digit NDC? I have DMBA ins out of Utah denying my claim for an 11 digit number. None of the other insurances have had issue and the only numbers on federal and sequrius site are 10. The rep told me something about this changing in 2019 to a 11 digit NDC??
Great references by @CBLENNIE above. However, I THINK you might really be asking "How do I convert a 10 digit NDC into the 11 digit format?"
The 11 digit format is 5-4-2. You add a zero at the beginning of the portion missing a digit. In your situation, since the format is 5-3-2, you would add the 0 to the middle portion.
70461-123-04 becomes 70461-0123-04
70461-123-03 becomes 70461-0123-03
Google has 100 references for this. Here's one:
The 11 digit format is 5-4-2. You add a zero at the beginning of the portion missing a digit. In your situation, since the format is 5-3-2, you would add the 0 to the middle portion.
70461-123-04 becomes 70461-0123-04
70461-123-03 becomes 70461-0123-03
Google has 100 references for this. Here's one: