American College of Physicians: Internal Medicine — Doctors for Adults ®

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How to define 'new' patients and code flu shots

From the December 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

Brett Baker

Q:

Current Procedural Terminology (CPT) defines a new patient as "one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." How does Medicare define a "professional service"?

A:

When determining if a beneficiary is a new or established patient, Medicare defines a "professional service" as face-to-face patient contact. For example, you could bill a new patient office visit, CPT 99201-99205, for the first evaluation and management (E/M) service you provide a patient, even if you have reviewed that patient's diagnostic test results (e.g., a chest X-ray or ECG) within the past three years. However, if in the past three years you have provided a patient any E/M service or procedure (e.g., a flexible sigmoidoscopy) that involved face-to-face patient interaction, you should bill the next visit as an established patient office visit, CPT 99211-99215.

Q:

Many of my Medicare patients are requesting a flu shot. What is the Medicare benefit and how do I get reimbursed?

A:

Medicare typically pays for one flu shot per beneficiary per flu season. It is important to note that Medicare does not limit coverage to one shot per 12-month period. It will pay for additional flu shots several times a year if medically necessary. It pays 100% of the Medicare-approved amount for the flu vaccination; neither the $100 per patient deductible nor the 20% co-insurance apply to flu shots.

If you accept Medicare assignment or agree to accept the Medicare allowable as payment in full, you cannot bill the beneficiary for any balance. Instead, you must bill Medicare for the flu vaccine and its administration. The payment amount will vary by geographic area.

If you do not accept Medicare assignment, you can charge for the vaccine and its administration (the same amount you would charge a non-Medicare patient), as these services are covered under a special benefit. However, you must submit an unassigned claim to Medicare on the beneficiary's behalf.

When billing for the flu vaccine and its administration, you must fill out the data fields required for any Part B claim. Select from CPT codes 90657-90659 to identify the vaccine product. Use HCPCS code G0008, "Administration of influenza virus vaccine," to report the administration of the vaccine. Use ICD-9 code V04.8, "Influenza vaccination and inoculation," if the sole purpose of the beneficiary's visit was to receive the flu vaccine.

You can bill HCPCS code G0008 to report the vaccine administration in addition to other services performed during the same visit, including an evaluation and management (E/M) service. You should append CPT modifier-25 to an E/M service code to indicate that it is a significant, separately identifiable service. Always justify each additional service with an appropriate diagnosis code. HCFA currently allows its carriers to determine whether to pay separately for the administration of a vaccine given on the same day as an E/M service.

More information is available on the CDC Web site at www.cdc.gov.

Q:

Does Medicare send beneficiaries information about what is covered by the program?

A:

Each year, HCFA publishes a handbook to inform beneficiaries about Medicare benefits. HCFA mailed this year's guide, called Medicare & You 2001, to more than 34 million beneficiary households and more than 300,000 physicians who care for Medicare patients. The handbook explains what Medicare covers and will enable you to discuss plan options with your patients. If you did not receive a handbook or would like additional copies to distribute at your office, you can download the guide from the HCFA Web site at www.medicare.gov/publications/overview.asp.

Brett Baker is a third-party payment specialist in the College's Washington office. If you have questions about third-party payment or coding issues, contact him at 202-261-4533 or bbaker@acponline.org.

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