Clarifying rules on new vaccines, oxygen prescribing
By Brian Whitman
Recent approval of vaccines for herpes zoster (shingles) and human papilloma virus (HPV) has been very exciting news for internists familiar with the devastating effects of these diseases. However, there may be some confusion over how to bill for the new vaccines and whether major insurers will pay for them. Some insurers do reimburse for these vaccines, but it is important to proceed on a case-by-case basis because coverage varies based on the patient's plan and individual characteristics.
How to bill for new vaccines
Q: How do I code for these vaccines?
A: In 2006, for the first time, the committee that maintains the Current Procedural Terminology (CPT) code book approved the inclusion of CPT codes for vaccine products for which FDA approval is anticipated but not yet granted. Those codes appear with a symbol that looks like a lightning bolt next to them in the CPT manual. This new inclusive approach allows physicians to report the code the day that the vaccine product is approved by the FDA. The shingles vaccine was approved by the FDA on May 25, 2006 and the CPT code for the vaccine is 90736. The HPV vaccine was approved on June 8, 2006 and the CPT code for the vaccine is 90649.
Q: Will insurers pay for these vaccines?
A: Many large private insurers approved payment for the new vaccines shortly after the FDA approved them. Because vaccines are preventive services, coverage may vary by patient and by plan. It's important to confirm that a patient is covered for a particular vaccine to ensure that you get paid.
Q: Will Medicare pay for these vaccines?
A: Although most physician-administered drugs covered by Medicare are paid under Medicare Part B, neither the HPV nor the shingles vaccines are covered in this way. Both vaccines can, but are not required to be, covered by Medicare Part D plans, the new prescription drug benefit for Medicare patients. Given the large variety of Part D plans on the market, it is once again necessary to look at individual information. The HPV vaccine is only indicated for females between the ages of nine and 26, so most Medicare patients would not be eligible. The shingles vaccine is indicated for patients over the age of 60, so the majority of Medicare patients will be eligible.
Q: Can I bill for administration of the vaccine using the vaccine administration codes?
A: Physicians may not bill Medicare for vaccine administration codes (CPT 90465-90474) for vaccines that are paid for under the Part D benefit, so those codes may not be used for the new vaccines.
Prescribing oxygen to Medicare patients
Q: Do I need to write a prescription to give oxygen to my Medicare patients?
A: Physicians are required not only to write a prescription for oxygen when appropriate for Medicare patients, but also to complete the form called DMERC 484.2 or the 'Attending Physician Certification of Medical Necessity for Home Oxygen Therapy.' Oxygen is provided by DME and home health providers and reimbursed under the durable medical equipment (DME) fee schedule.
Q: Why do I have to complete this form?
A: DME companies will not serve Medicare patients unless the form is completed, and Part B of the form must be completed by the physician or her staff. The physician’s staff may complete the form provided that they are working at the direction of a physician who has determined the appropriate medical course of action.
Q: What information must be included on the form?
A: The form requires two pieces of information. The first part requires the physician to document the laboratory study, usually a pulse oximetry in an internist’s office, which shows the need for home oxygen. The physician must also document the specifics of the oxygen system ordered for the patient, i.e., whether it is a liquid or gas system or if the patient will require a portable system.
Q: How often do I have to complete this form?
A: The form needs to be completed only once because an oxygen prescription must specify the number of months for which the prescription is valid. In some cases, physicians may prescribe oxygen for as long as 99 months. However, clinical practice may dictate that it is appropriate to reassess the patient’s need for oxygen at future visits.
Charging for missed appointments
Q: Can I charge a patient if he has missed his scheduled appointment?
A: A patient may be charged for a missed appointment provided that there is a missed appointment policy that is applied equally to all patients. This is one of the few fees that a physician can truly set the reimbursement for, but it would not be a good business practice to charge an exorbitant fee.
Q: What if the patient is on Medicare?
A: Medicare does not reimburse physicians for missed appointments. Typically, patients cannot be charged for services that Medicare does not reimburse for unless an Advanced Beneficiary Notice (ABN) is signed, but in this case, the patient may be charged for the missed visit.
Brian Whitman is Senior Analyst for Regulatory and Insurer Affairs in ACP's Washington office.
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