IRTR LogoBy Dr. C. Michael Soppet

As we approach influenza season, here are a few specific coding and payment items to make sure you receive the maximum allowable reimbursement for vaccines, and their administration.

1. Don’t forget Modifier 25
Many of you are aware of the 1996 Medicare and Medicaid Correct Coding Initiative (NCCI or CCI). To avoid over-payment for certain services, the NCCI intended to ensure that coding standards were uniform for Medicare claims submissions. One method was to promote certain computerized automatic “edits” to claims reviewed by Medicare Administrators for the different Medicare Area Contractors (i.e., companies who administer and pay claims for Medicare).

Edits occurred in two ways: Linking edits and Medically Unlikely Edits (MUEs). One of the edits was to determine that administration of vaccines usually occurred in a stand-alone or preventive services visit. CMMS has determined that submission of a vaccine code with an Evaluation and Management (E&M) Service Code is a MUE. Therefore, this edit precludes payment for both the vaccine and its administration, and E&M service on the same date. If you submit these together, they will not be paid.

CMMS does, however, permit the use of a Modifier to notify them that immunization was performed in this instance in addition to an E&M service by the physician. The appropriate modifier to use in this instance is Modifier 25. It is critical to attach the Modifier 25 to and submit on the same line as the E&M code. Do not add it to the immunization administration or vaccine code, otherwise the claim will be sent back unpaid. This common error often delays payment for both the E&M service (the lifeblood of Internal Medicine practices) and also the vaccine payment, reducing your return on invested capital.

2. Make sure you’re getting the best price
Based on experience, the purchase price for flu vaccines from physician purchase groups in 2015-16 had a range of $9-$10 per dose for IIV-3; $30-$33 for IIV-3 High dose; and $16-$18 for IIV-4 vaccines. The return on this investment (ROI) was reasonable. The national pricing manuals have not yet established the average wholesale pricing, so ROI for 2016-17 flu season cannot yet be estimated until Medicare Part B payment rates are set. Check the Medicare Payment Calculator at Medicare.gov weekly to see when the new pricing is available. Until the rates are set, you will be paid based on last year’s pricing for any submitted claims.

Next month we will look at pricing and payment for influenza vaccines approved for the 2016-17 season, what ACIP recommended regarding the various vaccines, their appropriate use, and expected ROI.

Helpful Resource: For a quick refresher on general billing and coding, please review Drs. Soppet and Jason Goldman’s presentation from the Key Largo training. It includes tips on coding and billing including the ICD10 and administration codes for adult immunizations.

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