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Charging Copays for Injections

  1. Default Charging Copays for Injections
    Medical Coding Books
    We have a lot of patients coming in for flu shots and weekly injections. They do not see the doctor; they see the nurse who does the education/assessment. My understanding is that we would bill for the injections and the vaccines/drugs, but not an office visit. What is the policy for billing a nurse visit (99211) with a 25 modifier, along with the injection and vaccine codes, and charging the patient a copay? I know that insurance companies won't pay for both the E&M and the injection/administration codes, but what are the legal ramifications of charging the copay?

    The practice's position is that they should charge the copay but I disagree. What say you?

    Thanks very much.
    Louise Cook, CPC

  2. #2
    I took this from, provider billing manual (chapter: billing for preventitive services) last night:

    10.2 - Billing Requirements
    (Rev. 1586, Issued: 09-05-08, Effective: 10-06-08, Implementation: 10-06-08)
    A Edits Not Applicable to Pneumococcal or Influenza Virus Vaccine Bills and Their Administration

    1 Billing for Additional Services If a physician sees a beneficiary for the sole purpose of administering the influenza virus vaccine, the pneumococcal vaccine, and/or the hepatitis B vaccine, they may not routinely bill for an office visit. However, if the beneficiary actually receives other services constituting an “office visit” level of service, the physician may bill for a visit in addition to the vaccines and their administration, and Medicare will pay for the visit in addition to the vaccines and their administration if it is reasonable and medically necessary.

    As far as the co-pay, I would think that copays are E&M specific: butIwould review a patient's benefits online with an insurance to double check. Hope this helps!

    Sunni Hearin--CPC

  3. Default Thanks
    Thanks for the info. Louise

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