Separate administrations of flu vaccines

dballard2004

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I was wondering if someone could confirm the correct way to bill and code for pediatric flu-shots for which patients will be coming in for two separate administrations of the flu vaccine. How do you recommend us billing for this and coding for this? I don't really think that the codes are going to be differant, but my docs are questioning this. Thanks.
 

Lisa Bledsoe

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Excellent question...we have this scenario as well, but as far as I can tell, even if given a split dose you can only bill once for the whole thing. Am I wrong?
 

dballard2004

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I am thinking the exact same thing. The feeling with my clinic is that they think that since it is two separate administrations, it is billed twice.
 

Lisa Bledsoe

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I don't think you will get paid twice for the same procedure even though it is done twice becasue you wouldn't normally encounter this situation - you get a flu shot once a year. I'd like to hear some other thoughts.
 

bhaskins1

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If the patient is under 9 years old and they have never had a flu shot, they should receive 2 shots, one month apart. There will be two encounters, two vaccines given so, you can bill for the administration and the vaccine both times. We do get reimbursed by insurance for both. Usually for smaller children, insurance does not question because they see that the DOS are one month apart and they have no prior history of flu vaccines... you may receive a denial on an older child (5yr+) but that is easily overturned with a phone call. Hope this helps.
 
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1st visit would be 90655 (if preservative free vaccine used), and 90465 if under 8 years of age and physcian counseled the family first (ie. WCC).

When coming back in for just the 2nd injection, charge 90655 + 90471. According to Sanofi Pasteur website, you can also charge 99211 along with this.

You might look at their website at some different billing scenarios.
 

stampinriz

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I had the same question myself and was told by our compliance coders to bill for both immunization and administration (either 90657/90658 and 90471) each time. I wasn't sure I agreed w/that, but per others here, sounds like it's worth a shot if we'll get paid for both! :eek:
 

fram

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fram, cpc

Hi,
I work for an FQHC and wanted to know if we bill and e/m code (99211) and the flu vaccine code and administration code, will we get paid?
 

bhaskins1

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Hi,
I work for an FQHC and wanted to know if we bill and e/m code (99211) and the flu vaccine code and administration code, will we get paid?
Only if 99211 is appropriate, you have to look at the services provided. Read the CPT instructions for the administration code and if your services go beyond that and are documented in the chart you have a case for 99211 but you cannot code it routinely. Services provided must warrant it.
 

bhaskins1

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Also... another way to look at the issue of two vaccines... yes we normally give 1 flu vaccine per year however it is widely accepted as standard to give two under the previously mentioned circumstances. Just as it is standard to give 3 HPV vaccines. You wouldn't consider not charging for the second and third HPV vaccine just because you had given it before. (at least I hope you wouldn't ;) ) Just a thought to maybe help some of you wrap your minds around charging for both. :D
 
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Regarding billing 99211 with flu vaccine in FQHC

In a FQHC, flu vaccines and pneumo vaccines are included on the Medicare Cost Report.
99211 visits cannot be billed as a FQHC encounter.
A FQHC billable service must include a face to face visit with a core provider. Clinical assistants or nurses are not core providers.

If you provide a flu vaccine or pneumo vaccine you should claim the appropriate administration code (90471) along with your vaccine code on your cost report.

Cms raised the RVU value of 90471 so billing a 99211 in addition to this is incorrect unless you have a medically necessary diagnosis to support billing 99211 in addition to the administration code for the flu vaccine.

If you do have a medically necessary diagnosis go ahead and bill 99211 to Medicare Part B only.
Claim the cost for the admin and flu vaccine on your Medicare cost report.
 

bhaskins1

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I do not bill Medicare (not much call for it in pediatrics) so I can't speak to how to bill Medicare specifically.

I agree that 99211 should not be used unless there is a medically necessary diagnosis.

I also just wanted to clarify that it is not appropriate to code 90465-68 unless the physician counsels the patient on the same date of service. If the patient comes in for the sole purpose of a flu vaccine and does not see the physician; 90471-74 would be the correct series to use for the administration of the vaccine.
 

maysons1703

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When would you code a 99211 E/M level for a flu shot? That does not seem appropriate to me, counseling and risk is included in all procedural services provided. If another diagnosis is addressed or assessed during the same visit by a privileged provider and meets the minimum 2 out of 3 requirement a level 2 with a modifier 25 should be assigned at the very least. If the 2 out 3 requirment is not met then a 99211 would be appropriate. Nurses/MA are not allowed to address/assess another diagosis without a physicians order.
Melissa
 
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bhaskins1

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I was only addressing a previous comment about 99211. We rarely if ever use it in conjunction with giving a flu shot... 9 times out of 10 if there is a complaint that requires e/m a physician steps in to handle the encounter. There are certain specific situations in our office that our RN's have been given authority by the physicians to triage... if this goes beyond the services covered by the administration codes we will code a 99211.

Don't forget you can code an e/m based on time also if more than 50% of the time spent was counseling... for a 99211 that would equal 2.5 minutes.
 
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