Coding & Billing Medicare Influenza Vaccines – Q Code Selection

As 2011 is drawing to a close, and new coding guidelines are being published and disseminated, M.E.D.I.C., Inc. wanted to take this opportunity to alert you to updates regarding seasonal influenza vaccine pricing.  As of September 1, 2011, payment allowances for flu vaccines have changed. 

In 2011, CMS stopped accepting CPT code range 90654-90662 for the influenza vaccine (note that commercial carriers still accept them, but Medicare will not).  Rather, those codes have been replaced by a series of Q codes which relate to the brand name of the vaccine:  Q2035 relates to Afluria; Q2036 relates to Flulavel; Q2037 relates to Fluvirin; Q2038 relates to Fluzine; and Q2039 relates to those not otherwise specified… all are defined as “Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use.”

Per CMS (http://www.cms.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp), the pricing allowance from September 1st, 2011 through August 31st, 2012 will be as follows:  95% of the Average Wholesale Price, as listed below: 

• Q2035 (Afluria): $11.543
• Q2036 (Flulaval): $8.784
• Q2037 (Fluvirin): $13.652
• Q2038 (Fluzone): $13.306
• Q2039 (N.O.S.): locally priced

Because the compensation differs for each product, providers must be sure to alert their billing staff/billing company to the specific brand of flu vaccine that is being administered to patients, so that they can ensure that claims are submitted to Medicare with the appropriate corresponding code.  In the event that the Q2039 “not otherwise specified” code is used, the claim will likely be denied, and additional information in the form of visit notes will be sought.  So, please – be sure to provide the brand specificity at the outset to ensure efficient processing and payment of your claims.

Furthermore, in addition to the Q codes, the HCPCS code G0008 for the Administration of the Influenza Vaccine must still be used for the administration of the flu vaccine for all Medicare patients.

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.

When billing flu shots to commercial carriers (i.e., non-Medicare), the Q codes are not applicable.  Practices will generally  code the following (but remember, the code used will depend on the route of administration (intramuscular vs. intranasal), the age of patient, the formulation, and whether the vaccine is preservative free, and split or live virus — each of which relate to influenza vaccine codes 90654-90668):

• CPT 90471 – Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid), and
• CPT 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use

RAC Approved Issue #1 — Coding Services Supplemental To Principal Procedure Code (Add-On Codes)

As discussed in the last post, this blog is going to dedicate some time to highlighting all of the approved issues for Region C’s Recovery Audit Contractor — Connolly.  Without further ado, the first item on Connolly’s list of “approved issues,” as identified by Connoly and CMS, which applies to physicians (as opposed to inpatient or outpatient facilities, ASCs, or DME suppliers) is:  the use of an add-on code without the primary code.  This audit issue is applicable to all of the states within Connolly’s Region C purview, and is applies to dates of service 10/1/2007  forward (however, it is important to note that the date of claim subject to a RAC audit cannot exceed three years from the current date — so, all the date of service must be no further back than May 8, 2008 for an audit sent today).

Pursuant to the CMS Manual, and the AMA’s CPT-Professional Edition, an add-on code designates a procedures which is commonly carried out in addition to the promary procedure performed (as distinguished from incidental services that are necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy), which are not separately billed).  These additional/supplemental codes enable physicians and others to separately identify a service that is performed in certain situations as an additional service, such as additional digit(s), lesion(s), neurorrhaphy(s), vertebreal segment(s), tendon(s), joint(s), or additional time.  These add-on codes are generally readily identified by terminology such as “each additional” or “list separately in addition to code for primary procedure,” or by a “+” symbol.  

Use of an add-on code is only appropriate when the same physician who provided the primary service also provided the additional add-on service.  Additionally, it is imperative that an add-on code never be reported as a stand-alone code — i.e., the add-on code must never be the only CPT code reported, rather, it must accompany the promary procedure code that it represents and enhances.  Finally, the add-on codes must never have the following modifiers appended to them:  -25, -51, or -59.  While all of these elements of the add-on codes are critical to compliant coding, it is the use od the add-on code as a stand alone code – without the primary CPT code – that will trigger a RAC investigation, for billing and subsequent payment of an add-on code without its respective primary code(s), results in unwarranted overpayments, repayment of which will be demanded by the RAC.