Category: Medical Billing and Coding

Medisoft v24
ICD-10medical billingMedical Billing and CodingMedisoftpatient payments

New Medisoft V24 Features

New Medisoft Version 24 Features

Medisoft released version 24 with several key new features. Among the new features is Transaction Entry Alerts. With alerts, you can create rules that notify billers of potential issues before sending a claim. Another new feature is enhanced eligibility response displays, which display distinct and expandable sections on a patient’s insurance eligibility, allowing for easier comprehension of eligibility status. Additionally, eMDs enhanced Medisoft’s mobile app with more information and better scheduling features.

Let’s take a quick look at each of these items.

Transaction Entry Alerts!

Is your billing department a one-person show trying to keep track of all the rules of billing your claims correctly? Do you have billing staff taking vacations and wanting to leave pages of notes for the person filling in while they are away? Or maybe you employ multiple billers working on your data simultaneously and need to enforce billing claims rules correctly the first time? Regardless of your billing situation, Transaction Entry Alerts may be a solution to creating cleaner claims during the entry process!

This new feature to Medisoft version 24 allows you to create rules based on many different criteria. Alert messages are displayed when saving transactions while you are still in the transaction entry screen. With these alerts, staff can resolve any issues before creating claims!

Below is an example of a simple alert that could easily shorten the processing time by days or even weeks if caught early in the process. The rule states that for a specific insurance company (MED03), when a data entry person enters a specific code (in this case, 99397), an alert appears within the Transaction Entry screen, notifying the user that the code is invalid. Furthermore, the message directs the user of the appropriate codes to use for Medicare (G0439 or G0438)

So, taking a few minutes to create an alert could save your company thousands of dollars or many hours working rejected or denied claims.

 Transaction Entry Alerts are one of the latest features added to Medisoft that allows you to take more control of your claim processing by ensuring your payers are getting the right information the first time a claim is submitted.

If you have a billing service or run multiple data sets within your practices, you can copy alerts created in one practice to any other practice, saving you time. We encourage you to check out transaction entry alerts. It may be the best thing you can do for yourself and your business.

Enhanced Eligibility Response Displays

This feature requires using a clearinghouse designed to integrate with Medisoft. Sunrise Services offers this through our clearinghouse partners at Change Healthcare. We recommend bundling electronic claims, insurance remittance posting, and eligibility services together. If you are already using and happy with a different clearinghouse, it may be possible to set up eligibility only through Change Healthcare, so you can use this new feature while maintaining your existing claims clearinghouse.

Eligibility displays are more readable and useful

With version 24, eligibility displays are more readable and useful.  They include expanding sections for better access to information. Here’s a screenshot from the new eligibility response display. Notice the different data sections, and you can click on a specific section to expand it and see more details. Version 24 provides a smoother workflow for your front-office staff to manage and find deductible amounts, coverages, and more.

General information appears in the header, as seen in the graphic below. Notice the green checkmark? It indicates that the patient has an active insurance health plan coverage.

Receive more detailed information in the sections below the header. Expand or collapse each section by clicking on the little arrow left of the section’s name. If the arrow points right, toward the section name, clicking the arrow expands that section, providing more details specific to that section. Expanding the section is called “drilling down” to see more information.

If the arrow points down, then clicking it collapses the section, and the detailed information becomes hidden from view. Drilling down into only the sections from which you want information makes for a cleaner and quicker query.

The example below shows an expanded deductibles section with the status of deductibles for both the individual and family. Please note that the information you receive is limited to what the insurance company releases through the clearinghouse.

In the below graphic, the bottom section, named Other Benefits, is a repository for other information not otherwise applicable to the other sections.

You can print the screen by clicking on the printer icon at the top left of the screen. Each section prints in its expanded or collapsed form, depending on how you are viewing the screen. For example, in printing this screen, the deductibles section includes detailed information because it’s expanded. The other sections are all collapsed and show no details on the printout. If you also wanted to print out Active Coverage details, then expand that section before printing.

You can also print a specific section by Right-clicking on that section and selecting the Print option.

Medisoft Mobile App v3.2

With Mobile App 3.2, eMDs implemented both back-end development upgrades and numerous new feature capabilities.

The patient’s middle initial is now visible on the patient card view. The middle initial also appears on the following screens: charges, patient search results, and new appointments.

The case number and its description now appear on the patient card. Which case appears depends on several factors.

  • If the patient is on the appointment list AND the appointment has a case, the information from that case appears
  • If there is an appointment, but no case was selected, then no case information appears because the entry operator could have selected a case and chose not to.
  • And finally, if there is no appointment and the patient has one or more cases, information from the case appears and is based on your Program Option settings.

eMDs added new information to the Patient Card screen as well.

You can now view Secondary and Tertiary Insurance information on the patient’s case. And for all insurances, policy and diagnosis codes from the listed case now appear on the patient card. You can also see diagnosis codes from the case and the patient’s balance views.

Medisoft features Guarantor (or family) billing. You can send one statement to an entire family that includes each member’s balance. The sum of all those balances is called the quick balance. In Medisoft, you view the quick balance by pressing F11. That balance was not previously available from the mobile app. Now, when you tap the balance on the screen, you can see the guarantor’s quick balance.

You can now select a case when creating an appointment in Medisoft Mobile. Previously, you could review existing appointments and add new appointments. Unfortunately, you could not edit, move, or delete an appointment. With version 24, you have much more control over the entire appointment entry system in Medisoft.

If you already have Medisoft version 24, you can view our online training videos at www.sunrize.com/Medisoft. Or, check the Medisoft help menu for more details. If you do not currently use version 24 and would like to upgrade, please contact our sales department 502-538-4665 option 1 or contact sales@sunrize.com.

accountingaccounts receivableICD-10medical billingMedical Billing and Coding

Medisoft V24 A/R Tracker

Are you on version 23 or 24 of Medisoft Advanced or Network Professional? Have you looked at the new AR Tracker yet? If you answered “No” to either question, keep reading.

A new feature added in version 22, the “AR Tracker” module deserves an award. It is a very flexible tool that can save you time and much money by getting better control over your Accounts Receivable. It doesn’t matter if it’s just you or a staff of 20. The AR Tracker can help keep your AR efforts under control and more focused.


Do I have your attention yet? Many of you have a system of reports, notes, Final Draft messages, and color codes to help in your efforts already. You don’t have to change the way you do everything! However, you may find many of your AR efforts obsolete in a matter of minutes!

Accessible from the Activities drop-down menu, the AR Tracker pulls much of the critical information you need into one location, tying together AR management into one cohesive workflow, with advanced filtering to track and collect Insurance and patient balances.

Find and sort claims and statements in ways you didn’t know to wish for! Search results filter down by the provider, then insurance, the patient, and finally the claim number, where you can see any transaction color-coding, aging information, and so much more. From those results, you can create a task for a Medisoft user and track the outcomes.

“As an administrator, you can make sure that tasks are getting worked on and completed by their assigned follow-up dates.”

A simple right-click on a claim or statement will open the door to many of the tools you need to assist your AR process.

  • Add or view notes that are date stamped (so you can keep track of what has been done by you or others in your office)
  • Assign Status and Task codes then assign them to another staff member or yourself with a follow-up date (which a user can then use in the tracker to find his or her tasks to target the AR before it is lost)
  • Open and edit the insurance, patient, or claim and return right back to the AR Tracker list. Go straight to the patient’s transaction entry screen or to their case. Even check eligibility if you’re a Change Healthcare user.

If you have created a task for a Medisoft user, you can then create a filter template specifying the user and, or task code. The user then quickly opens the AR tracker and selects their templet to immediately target claims and statements they need to work on and enter follow up notes.

As an administrator, you can make sure that tasks are getting worked on and completed by their assigned follow-up dates.

Medisoft version 24 further enhances the module with a new field in the insurance carrier screen to enter the timely filling days. While editing an insurance, in the Address tab you’ll find the new Timely Filing Days field. Enter the number of days this insurance allows for a claim to successfully adjudicate. Back in the AR Tracker, you will notice a new column in the Details grid for claims: Days to File Pri. This column shows you the number of days before this claim reaches the timely filing deadline for that insurance carrier when it is the Primary insurance.

And it’s not just your billers that will benefit from the AR Tracker. Your front desk person using office hours can benefit from seeing Patient AR Status codes while scheduling or checking in patients. Data entry persons can get Pop-up messages when entering charges based on the same codes.

Human resourcesMDSuiteMedical Billing and CodingRevenue Cycle Management

The Importance of Soft-Skills in Healthcare

The landscape of healthcare organizations has changed dramatically over the past few decades. The concept of “healthcare consumerism” has gained significant traction with health systems, hospitals, and medical practices. Healthcare consumerism is a movement that advocates patients’ involvement in their healthcare decisions-moving away from the mindset of “do what the doctor says” to a model of a working partnership between the doctor and patient. Previously passive patients have become empowered consumers due to the extreme financial burden placed on their personal paychecks. This shift towards value-based care impacts how patients are cared for and how physicians and hospitals are paid. The rise in consumerism in healthcare is pervasive and has created a workplace that is more demanding, more complex, and more collaborative than ever before.

Healthcare organizations will need to hire and train healthcare employees with the right professional skill sets to provide well-coordinated, high quality, patient-centered care. Finding healthcare workers who will contribute to the value-based care environment means hiring staff with the right balance of hard and soft skills.

While hard skills are related to technical knowledge and training, soft skills are personality traits. Candidates should possess exceptional skills in communication, teamwork, critical thinking, and adaptability. Soft skills were often overlooked in the past but should be considered a core criterion for hiring today. 

According to SkillSurvey Inc., 2019 soft skills are a collection of personal, positive attributes and competencies that enhance their relationships, job performance, and add value to the market. In today’s workforce, soft skills should be considered essential to managing and working with people, customer satisfaction, and forming a positive work environment. When patients encounter rude behavior from medical staff, there is an increased likelihood of labeling future interactions as rude and as such patients are more apt to be rude in turn. Patient care suffers because people are afraid to speak up, and the level of ambient rudeness goes up. 


Here are five tips to help leaders find the best candidates for their organization (National Association of Colleges and Employers (NACE) 2015; Parker 2011; Skill Survey Inc 2019)

  1. Make soft-skills part of your organizational culture.

  2. Identify soft skills that matter to the position you are hiring

  3. Design job descriptions to communicate required soft skills

  4. Conduct a detailed assessment prior to extending an employment offer

  5. Make soft-skills part of your organizational learning and development programs.

Mastering soft skills is an on-going process and should continue throughout a person’s professional career. Proper use of soft-skills can not only create valuable healthcare team members but also creates an environment to provide the best patient care.

EHRmedical billingMedical Billing and CodingRevenue Cycle ManagementTelehealth

Understand How To Code Telehealth, Telemedicine

Hint: The terms aren’t interchangeable.

Providers are increasing patients’ access to healthcare services through virtual communications. If providing services to patients without an in-person, face-to-face interaction makes sense for your practice, it’s important for you to know how to code the services correctly.

TelehealthWhile you may hear telehealth and telemedicine used interchangeably, from a coding perspective, the words refer to different services and situations.

Definitions:  A good place to start is by outlining the difference between telehealth (defined as any health service provided by telecommunications) and telemedicine (defined as any clinical service provided by telecommunications). Additionally, you’ll want to consider the array of nuanced guidelines and constantly changing code sets.

Have a look at three key areas to cover some of your most pressing telemedicine and telehealth services’ coding needs:

 

  1. Keep an Eye on Changes

“One of the greatest challenges facing telemedicine coding is that changes in technology typically occur faster than changes in coding,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

“CPT® code change proposals are often generated and acted upon more than a year before the changes/new codes appear in CPT®, and CPT®itself is only published once a year. So, it’s easy to see how technology moves faster, leaving coders to wonder if a new telemedicine service fits an existing code or needs to be reported using an unlisted code,” Moore adds.

As an example of this rapid change, theCenters for Medicare and Medicaid Services(CMS) introduced two new HCPCS codes for 2019: G2012 (Brief communication technology-based service, e.g. virtual check-in…) and G2010 (Remote evaluation of recorded video and/or images submitted by an established patient…), which you can use when a provider is evaluating information to determine if a patient needs to be seen in the office.

Additionally, CMS added two prolonged service codes, G0513 (Prolonged preventive service(s) … first 30 minutes…) and G0514 (…each additional 30 minutes…), to the telehealth services’ list.

One means of staying current with telemedicine codes is consulting Appendix P in your CPT® manual. Documenting any service listed there when provided via telemedicine is as easy as appending modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system). You will also need to add place of service (POS) code 02 (Telehealth) to your claim to indicate that the provider is at the distant site (as opposed to the originating site where the patient is located).

GT no longer needed: Unless you are billing claims from a critical access hospital (CAH) under method II for institutional claims, you no longer need to apply modifier GT (Via interactive audio and video telecommunication systems) to a Medicare telehealth claim. But modifier GQ (Via asynchronous telecommunications system) is still required for asynchronous communication when appropriate, says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

2. Know What Qualifies as Telemedicine

While telemedicine can involve the use of telephone communication, two groups of telephone evaluation and management (E/M) codes are not regarded as telemedicine.

Codes 99441 through 99443 (Telephone evaluation and management service by a physician or other qualified healthcare professional … provided to an established patient, parent, or guardian …) and 98966 through 98968 (Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian …) are not regarded as telemedicine because CPT®does not regard them as being “face-to-face” services.

Medicare Advantage Now Features Telehealth Expansion

In the past, telehealth was only an option offered through Medicare Advantage beneficiaries’ supplemental benefits, but the Centers for Medicare and Medicaid Services (CMS) wants to change that.

Now: Bolstered by provisions outlined in the Bipartisan Budget Act of 2018 (BBA 2018), CMS updated telehealth services for Medicare Advantage (MA) plans starting in the contract year 2020, notes a two-part final rule, published in the Federal Register last month.

“Under this final rule, MA enrollees may have great opportunities to receive healthcare services from places like their homes, rather than being required to go to a healthcare facility,” CMS advises. “MA plans will now have broader flexibility than is currently available in how they pay for coverage of telehealth benefits to meet the needs of their enrollees.”

The final rule allows MA plans the option to offer telehealth benefits to MA patients beyond their supplemental benefits in both rural and urban environments, aligning with BBA 2018 legislation, indicate attorneys Matthew M. Shatzkes and Susan Ingargiola of the national law firm Sheppard, Mullin, Richter & Hampton LLP, in the Sheppard Mullin Healthcare Law Blog.

However, “MA Plans will continue to be able to offer MA supplemental benefits (that is, benefits not covered by fee-for-service Medicare) via remote access technologies and/or telemonitoring for those services that do not meet the requirements for coverage under fee-for-service Medicare or the requirements for MA additional telehealth benefits (such as the requirement of being covered by Medicare Part B when provided in-person),” Shatzkes and Ingargiola explain.

The same is true for 99444 (Online evaluation and management service provided by a physician or other qualified healthcare professional … using the Internet or similar electronic communications network), which is also regarded as non-face-to-face and would also not be defined as telemedicine by virtue of its asynchronous nature.

3. Don’t Forget Difference Between State and Federal Rules

Depending on the nature of the telehealth service and the clinical care administered telemedically, CMS may not cover the outcomes.

“The key to compliance with Medicare rules is to evaluate the Medicare billing requirements for a bona fide telehealth encounter with the proposed arrangement from the telehealth company,” says John E. Morrone, a partner at Frier Levitt Attorneys at Law in New York City. “It is very common for healthcare services to comport with applicable state law but not be reimbursable by Medicare.”

He adds, “A telehealth encounter may be perfectly acceptable under state law, and even billable to commercial carriers, but not be billable to Medicare.”

Resource: For a more in-depth look at CMS’s telehealth services, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf?utm_campaign=2a178f351b-EMAIL_CAMPAIGN_2019_04_19_08_59&utm_term=0_ae00b0e89a-2a178f351b-353229765&utm_content=90024810&utm_medium=social&utm_source=facebook&hss_channel=fbp-372451882894317.

 

Originally published Published on Thu Jun 06, 2019, TCI

New Patient Image
MDSuitemedical billingMedical Billing and CodingMedisoft

What Makes A New Patient “New”?

A patient makes an appointment at your clinic and “has never been seen before”, you bill a new patient visit only to have the payer reject the claim, stating, “New patient qualifications have not been met”.

So, what went wrong?  Not all Evaluation and Management (E/M) codes fall under the new (versus established) categories.  For example, if the patient presents through the Emergency Department, the patient is always new, and the provider is always expected to get the patient’s history to diagnose a problem.  However, in the office setting, the patient sees their primary provider routinely.  The provider knows- or can quickly access- the patient’s history to manage their chronic conditions, as well as make decisions on recent problems.

The definition of a new patient in the CPT code book is: “one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”  In addition to this definition, CMS adds “an interpretation of a diagnostic test, reading an X-ray or EKG etc., in the absence of an E/M service or other face to face service with the patient does not affect the designation of a new patient.”[i]

Three key components that make up a new patient are:

  1. Professional Service (not modifier 26)– If the provider has never seen the patient face to face, a new patient code should be billed.
  2. Three-year rule- the general rule to determine if a patient is “new” is to check to see if that patient has been seen in the past three years. Check your dates on this-if the patient was seen the last time in May of 2015 and its March of 2018, it hasn’t been three years, according to the payer.
  3. Different specialty/subspecialty within the same group is possibly the most confusing. For Medicare patients, use the NPI registry to see what specialty the physician’s taxonomy is registered under.  The credentialing process is of upmost importance in ensuring no denials happen due to improper credentialing.

What happens when doctors switch practices?

If a doctor changes practices and takes his patients with him, the provider cannot bill for the patient as a new patient based on the “new” tax ID.  The tax ID doesn’t matter because the provider has already seen these patients and has established a history.  Just because the patient is being seen in a new facility, that patient is still seeing the same provider.

What happens when a provider sends the patient to mid-level provider?

When an MD or DO sends a patient to a mid-level provider (Nurse Practitioner or Physicians Assistant) and the visit is not an incident-to, the mid-level provider could bill a new patient code if they are a different specialty with different taxonomy codes.  An example would be a family practitioner and the mid-level sees hematology patients.  Since the specialty is different, the mid-level could bill as a new patient visit.  However, if the mid-level is also considered family practice, then a new patient visit code could not be used.

Of course, in billing there are always exceptions to the rules.

For example:

  • For some Medicaid plans, obstetric providers need to bill an initial prenatal visit with a new patient code, even if they have seen the patient for years prior to the patient’s pregnancy. Make sure you check your own local rules and Medicaid plans if you are billing obstetrics.
  • Hospitalists and Internal Medicine providers are the same specialty according to Medicare, even though each has a different taxonomy code.

If a new patient claim is denied, look to the medical record to see if the patient has been seen in the past three years by your group.  If so, check to see if the patient was seen by the same provider or a provider of the same specialty by checking the NPI registry website.  It’s always helpful to know how the provider is registered with the payer denying the claim.  If in researching all of this, there isn’t any substantiating evidence to support the denial, appeal the claim.

 

[i] Medicare Claims processing manual, chapter 12-Physican/Nonphysician Practitioners (30.6.7)

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New PT CPT Codes for 2017

pt-with-patient

CPT® 2017 has a few expanded codes for physical therapy evaluations and follow-up exams.  These codes are in effect for dates of service starting January 1, 2017.

97001 to be replaced by three codes in 2017:

These new codes will add more specificity and details regarding the scope of the evaluation and states that it involves clinical decision-making of low/moderate/high complexity. The evaluation includes history to identify any factors that impact the plan of care; using standardized tests and measures to assess body structures and functions that may limit activity or restrict participation; and evaluation of the patient’s current status on presentation. The evaluation typically includes face-to-face time with the patient and/or family.

97161 Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.
97162 Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97163 Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.

CPT® 2017 adds 97164 to replace 97002 (Physical therapy re-evaluation).

The new code adds more specificity and details regarding the scope of the evaluation, which includes history review and standardized tests (criteria established and agreed upon by a group of experts) and measures to assess body structure and function; a revised plan of care using standardized instrument and measurable functional outcome assessment tool; and typically involves 20 minutes of face-to-face time with patient and/or family.

Consider these to be the equivalent of E&M codes (99000) for Physical Therapy.  You should now consider these elements when coding for services:

  • Patient’s history
  • Examination results
  • Clinical decision-making
  • Development of the care plan

The level of the PT evaluation performed depends on the clinical decision-making and the patient’s severity, according to CPT® instruction. For reporting, PTs must demonstrate review of these body regions and body systems:

  • Defined body regions such as the head, neck, back, lower extremities, upper extremities, and trunk
  • Musculoskeletal systems, which include gross symmetry, range of motion, strength, height, and weight
  • Neuromuscular systems, which includes gross coordinated movement and motor function
  • Cardiovascular and pulmonary systems, which include heart and respiratory rates, blood pressure, and edema
  • Integumentary system, which means assessing the pliability, scar formation, color, and integrity of the skin

One other thing-make sure to sequence these codes before your modality CPT codes (those starting at 97010).

OT and AT have similar changes.  Look for those in a future post.

References:
CPT® 2017 Professional Edition, American Medical Association, pages 664-668
Federal Register, Vol. 81, No. 136, Pat. 46162, July 15, 2016, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other revisions to Part B for CY 2017; Medicare Advantage Pricing Data Release: Medicare Advantage and Part D Medicare Advantage Provider Network Requirements’; Expansion of Medicare Diabetes Prevention Program Model”
AAPC Healthcare Business Monthly, November 2016

 

ICD-10Medical Billing and CodingMedisoft

It’s the holiday season….time to spread the Flu!

santa-hat

With all the weather changes we have experienced in the south over the past few months, getting the flu has been the last thing on anyone’s mind.  80 degree temps here in Kentucky in November is unheard of!  We’ve all been taking advantage of getting out in the fresh air (flu?  what flu?).

Well, now we are experiencing our first “Arctic Blast” and my first trip to Kroger this week resulted in witnessing probably the most embarrassing thing we as parents experience….projectile vomiting from a child in the grocery store.  Okay, maybe not the most embarrassing thing in the world but one that certainly had me running for the hand sanitizer and masks (no-I didn’t stick around to help).

And yes, remembering that in fact, the flu season is upon us.

Guidelines for Billing Influenza Vaccines

Medicare pays for one seasonal influenza virus vaccination per influenza season (12 months do not have to pass). Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations. All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine.

Medicare will pay both administration fees when a beneficiary receives both the seasonal influenza virus and the pneumococcal vaccines on the same day. Report ICD-10-CM diagnosis code Z23 Encounter for immunization when an individual receives both vaccines, but report separate administration codes for the seasonal influenza virus (G0008) and pneumococcal (G0009) vaccines.

Medicare Payment Allowances for this flu season (8/1/2016-7/31/2017)

CPT® Code Payment Allowance
90630 Influenza split virus vaccine, quadrivalent (IIV4), preservative free, for intradermal use $20.343
90653 Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use $37.383
90654 Influenza virus vaccine, split virus, preservative-free, for intradermal use Pending
90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use Pending
90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use $17.717
90657 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6–35 months of age, for intramuscular use Pending
90661 Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use Pending
90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use $42.722
90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use $26.876
90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use $40.613
90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use

*NOTE-Claims for this code must be held until 1/1/17

$22.936
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use $26.268
90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use $19.032
90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6–35 months of age, for intramuscular use $9.403
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use $17.835

 

HCPCS Level II Code Payment Allowance
Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria) $16.284
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval) $16.284
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin) Pending
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) Pending
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) Flu Vaccine Adult – Not Otherwise Classified: Payment allowance is to be determined by the local claims processing contractor.

The payment allowance for some codes is still pending. Check the CMS website periodically for updates.

Resources:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2016-12-08-eNews.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending#_Toc468862699