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


Billing tips to ease the aches and pains of flu season

Plus, how to tell which Medicare patients are covered for abdominal aortic aneurysm screening

From the November ACP Observer, copyright 2006 by the American College of Physicians.

With flu season underway, physicians once again are urging their patients to come in for immunizations, hoping that their supply of vaccine will meet this year's demand. With different forms of vaccine available and changes to Medicare coverage, payment issues are also a concern. Here are some tips to survive the season while staying in the black.

Q: It is flu season again. Remind me again how to bill for administering the flu vaccine?

A: As with any vaccine, a physician or physician's staff administering an influenza vaccine should use two codes, one for the vaccine itself and one for the administration. There are a number of codes that can refer to the flu vaccine if you flip through the CPT manual.

Q: How do I bill Medicare for the administration of the vaccine?

A: For a Medicare patient, there is only one HCPCS code that may be used for flu vaccine administration: G0008. It is important to note that this code is described in the HCPCS book as "administration of influenza virus vaccine when no physician fee schedule service on the same day." This description is, however, incorrect. A physician may bill Medicare for the administration of an injection and an office visit or another procedure on the same day and be paid the full fee schedule amount for both services. No modifier is required in this case, but both the administration of the injection and the other service must be properly documented.

Q: What about for private payers?

A: For private payers, the CPT codes for administration likely will differ based on the method and the age of the patient. If using an injection for an adult patient, you would bill for the administration using 90471. If you are administering the nasal vaccine, you would use code 90473.

Q: Now that I have billed for the administration, I need to get paid for the drug. How do I bill for that?

A: Physicians should use CPT code 90658 for the injectable version of the drug that contains preservatives. If a preservative-free version of the injectable drug comes on the market during the 2006-07 flu season, physicians should use CPT code 90656. The majority of vaccines would be coded using 90658, as in past years. Medicare and most private payers reimburse for the traditional 90658.

If you administer the nasal flu vaccine, you should use CPT code 90660. This vaccine is not indicated for individuals older than 49, so most Medicare beneficiaries would not be eligible. Medicare has not issued a national coverage decision (NCD) on nasal flu vaccine, but it is best to stick to the injection if you wish to be paid by Medicare.

Q: Do Medicare patients have to wait a year between flu shots?

A: Medicare will cover one flu vaccination per season without a physician order. For example, if a patient received a flu vaccination in January of 2006, he could receive another flu vaccination in October of 2006, because it is a different season. They do not have to be a full year apart.

Abdominal aortic aneurysms

Q: I have patients who meet the risk factors for ultrasound screening for Abdominal Aortic Aneurysm, but since Medicare does not cover this service, these patients cannot afford to get the procedure. What should I do?

A: Medicare has historically not paid for preventive services, only adding a few at a time through legislative action. Congress recently mandated that, starting Jan. 1, 2007, ultrasound screening for abdominal aortic aneurysm be covered, but specified some requirements that may make it difficult to refer patients and for the physician reading the test to get paid.

The biggest obstacle to the coverage is that, in order to be paid, the patient must be referred for the screening during the Initial Preventive Physical Examination, also known as the "Welcome to Medicare" exam. This is the preventive visit that was introduced in 2005, covering a screening exam for patients in their first six months as a Medicare Part B beneficiary. The number of eligible patients who receive the "Welcome to Medicare" exam is quite low, however. This means that patients who have been on Medicare for more than six months and who have not had the screening exam cannot receive the benefit.

Q: Who is eligible to be referred for the benefit as paid by Medicare?

A: Beneficiaries who meet the conditions set forth by the U.S. Preventive Task Force recommendations are eligible to be referred for the screening and covered under Medicare. The current guidelines allow payment for males between the ages of 65 and 75 who have smoked at least 100 cigarettes in their lifetime.

Brian Whitman is Senior Analyst for Regulatory and Insurer Affairs in ACP's Washington office.


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