Wiki Flu Shots

[GINNYV]

What is the protocol for billing for flu shots?

 

[Diana Lerro]

You may bill for both the vaccine (90655-90658) and the administration (G0008 or 90471).

 

[dmmsg]

do you use a modifier 25 when done with an office visit?

 

[bhaskins1]

A modifier is not necessary but you want to be sure that you are not billing an office visit for someone who only received a shot. You can only code an E/M if the physician provides and documents a valid E/M.

 

[dmmsg]

Thank you, there was some confusion on this. Some people say do & some
don't. I agree with the don't.

 

[dmaec]

we modify the office visit if the patient has one, and also has a flu shot. The E/M significant, separately identifiable from the "added" flu shot. If they're coming in for flu shot only - then there isn't an E/M (or a need for a modifier then).

 

[bhaskins1]

we modify the office visit if the patient has one, and also has a flu shot. The E/M significant, separately identifiable from the "added" flu shot. If they're coming in for flu shot only - then there isn't an E/M (or a need for a modifier then).

I don't happen to agree... if a child comes in for a sick visit and the Doctor sees that it is also time to update a vaccine (lets say Dtap or Hep A) we don't add modifier 25 so why would we add it for Flu? It's still just a vaccine. I guess there may be a commercial carrier that requires it or perhaps a state Medicaid program but I bill most of the major commercial carriers (UHC, BCBS [North Carolina], Aetna, Cigna, Medcost) and none of them deny payment on the office visit if it has it's own diagnosis attached.

example:
e/m 99213 729.5
admin 90471 V05.9
vaccine 90633 V05.3

I can see how the use of Modifier 25 would make sense but I have not found it to be necessary in my experience.

 

[codecrazy]

But we are talking pediatrics so if under 8yrs. 90465-90468 right?

 

[Lindsey_McBee]

under 8 admin codes

the 90465 etc. should only be billed if there is documentation in the chart that they physician counseled the patient (or in this case, parents) on the pros/cons of the vaccine. If there is not documentation that the counseling occurred then you should use the 90471 etc.