Step 7B How to Bill for Adult Immunizations

step ₇b: How to Bill for Adult Immunizations Health insurance coverage of adult vaccines • Private Insurance – Most private health insur - ance plans cover the cost of providing recom - mended vaccines to your patients. If your patients do not currently have health insurance, refer them to www.HealthCare.gov to learn more about their healthcare coverage options. • Medicare – For patients 65 years of age or older enrolled in Medicare, Medicare Part B covers the cost of influenza and pneumococcal vaccines, as well as hepatitis Medicare Part B covers B vaccine for per - sons at increased the cost of influenza and risk of hepatitis B. pneumococcal vaccines, as hough preventive care , patient convenience, Patients with a and expansion of services are good reasons well as hepatitis B vaccine T Medi care Prescrip - for providing vaccinations to adults, adequate reim - for persons at increased tion Drug Plan bursement offers an additional incentive. When risk of hepatitis B. (Part D) or who are vaccination services are billed appropriately, private enrolled in a Medicare Advantage Plan (Part C) insurance companies generally reimburse for adult that offers Medicare prescription drug coverage immunizations, and Medicare covers routinely may also have coverage for additional vaccines like prescribed adult immunizations. By following some zoster and Tdap. Additional information is avail - simple guidelines, you can minimize administrative able at www.medicare.gov . hassles in billing for these services. Vaccine coverage for Medicaid beneficiaries varies by state. Contact your State Medicaid Agency for more information. Adapted and updated by Immunization Action Coalition, • Medicaid – Vaccine coverage for Medicaid courtesy of the American College beneficiaries varies by state. Contact your State of Physicians, 2015 Medicaid Agency (contact information available at www.medicaid.gov/about-us/contact-us/ www.acponline.org/running_ contact-state-page.html ) for more information. practice/payment_coding/coding/ billvaccines.pd f Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org 110808 step ⁷b: How to Bill for Adult Immunizations This section summarizes Medicare Part B regula - Billing Medicare for immunizations tions in plain English and provides charts to help Medicare Part B covers the cost of influenza and you properly code vaccinations for both Medicare pneumococcal (both PPSV23 and PC V1 3) vaccines, Innovative billing techniques, when combined as well as hepatitis B vaccine for persons at increased risk of hepatitis B. Medicare Part B does not cover with chart reminders, standing orders, and other vaccinations unless they are directly related to other methods of standardizing your office the treatment of an injury or direct exposure to a dis - operations, can substantially reduce the costs ease or condition, such as anti-rabies treatment, of administering vaccinations in your office. tetanus antitoxin, and Td/Tdap for wound manage - ment. Therefore, in the absence of injury or direct and third-party billers. It also explains how innova - exposure, preventive immunization against diseases tive bill ing techniques, when combined with chart such as pertussis, diphtheria, etc., is not covered reminders, standing orders, and other methods of standardizing your office operations, can substan - tially reduce the costs of administering vaccinations in your office. Additional information on improving immunization rates in your practice is found in IAC’s Strategies to Improve Adult Vaccination Cover - age , available at www.immunize.org/catg.d/p 2050 .pdf , as well as on the immuni - Strategies to Improve Adult Vaccination Coverage Many vaccines are recommended for adults, but vaccines don’t work unless we zation websites for the get them into the arms of the people who need them. Despite the fact that there DUHVDIHDQGHƪHFWLYHYDFFLQHVGLVHDVHVWKDWFDQEHSUHYHQWHGE\WKHVHYDFFLQHV continue to take a huge toll among adults in the United States. Low adult vaccination coverage rates occur for a variety of reasons, including low community demand for vaccines, lack of access to vaccination services, and system- and provider-related factors. Successful adult vaccination delivery depends on several patient and provider factors, as Ameri can College of Physi - well as system issues, such as vaccine effective strategies supply and reimbursement. Unequivocal provider Adults are unlikely to seek vaccination unless they believe recommendation that the disease is a threat to them and that there is a vaccine that can prevent the disease. They need to know Standing orders protocols that they are personally at risk. Even if they know a vaccine cians ( http://immunization. is available, adults also may have misconceptions about Reminder and recall the vaccine and inordinate concerns about vaccine systems adverse reactions. Assessment and feedback $NQRZOHGJHDEOHSURYLGHUZKRXVHVHƪHFWLYHVWUDWHJLHV Expansion of OLNHWKHRQHVVXJJHVWHGEHORZFDQDGGUHVVWKHVHLVVXHV patient access acp online.or g An unequivocal provider recommendation is crucial. ) and other tOne of the leading reasons adults identify for not receiving a vaccine is the lack of a recommendation from their provider. tAn unequivocal vaccine recommendation by an adult’s healthcare provider is one of the most important interventions to improve patient acceptance of a vaccine. tProviders often don’t appreciate the power of their recommendation of a vaccine, or the impact of their lack of a recommendation. Most adults rely on their providers to let them know which medical associations and vaccines are recommended and when they should be given. Standing orders protocols work. t6WDQGLQJRUGHUVSURWRFROVDUHDVHULHVRIZULWWHQPHGLFDORUGHUVDXWKRUL]LQJDTXDOLƫHG LH eligible to do so under state law) healthcare professional to assess the need for and administer vaccine to all persons meeting certain criteria (such as age or underlying medical condition), eliminating the need for an individual physician’s order for a patient’s vaccine. organ izations listed in Step under Medicare Part B. These vaccines and other t6WDQGLQJRUGHUVKDYHEHHQVKRZQWREHWKHPRVWFRQVLVWHQWO\HƪHFWLYHPHDQVIRULQFUHDVLQJ vaccination rates and reducing missed opportunities for vaccination. tStanding orders templates for all routinely recommended adult vaccines are available from IAC at www.immunize.org/standing-orders. continued on the next page 7A: Financial Considerations . commercially available vaccines (such as zoster) Saint Paul, Minnesota t 651-647-9009 t www.immunize.org t www.vaccineinformation.org www.immunize.org/catg.d/p2050.pdf t Item #P2050 (9/17) Later in this section you can typically are covered by Medicare Part D drug plans www.immunize.org/ find the codes you will need when they are ACIP-recommended to prevent ill - catg.d/p 2050 .pdf to bill. ( Table 3: Immuniza - ness. Billing for Part D vaccines goes directly to the tion Codes Used to Bill Medicare and Table 4: Immu - third-party drug coverage plan. nization Codes Used to Bill Third-Party Payers .) Though not reimbursed directly through the Medi - care Physician Fee Schedule, the administration of influenza, pneumococcal, and hepatitis B vac - cines (HCPCS codes G0008 , G0009 , and G0 010) is reimbursed at the same rate as CPT code 90471 for the year that corresponds to the date of service of the claim. Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org step ⁷b: How to Bill for Adult Immunizations 109109 Billing Medicare for additional services For Medicare Part B submissions, physician prac - tices and other mass immunizers must submit a When administering influenza, pneumococcal, separate preprinted CMS-1500 paper claim form or and/or hepatitis B vaccines, you may bill for addi - bill electronically for each type of vaccination (either tional reasonable and necessary services. For influenza or pneumococcal) and attach a roster bill example, you can bill HCPCS G000 8 for adminis- containing information for two or more Medicare tering influenza vaccine and also bill for other serv - beneficiaries. When mass immunizers choose to ices performed during the same visit, including an conduct roster billing electronically, they are required evaluation and management (E&M) service. Each to use the HIPAA-adopted ASC X12N 837 claim additional service should always be justified with standard. Local Medicare Administrative Contractors an appropriate diagnosis code. (MACs) may offer low or no-cost software to help However, if you use “roster billing” (see below), providers utilize roster billing electronically. How - you should not list additional services on the ros - ever, this software is not currently available nation - ter bill. All other covered services, including office wide, so check with your local MAC for specifics visits, are subject to more comprehensive data in your area. requirements; you should bill them using normal All entities that submit claims on roster bills must Part B claims filing procedures and forms. accept assignment, meaning they must agree to Roster billing also can substantially lessen accept the amount that Medicare allows as the total the administrative burden on physician payment. Roster bills submitted by providers to a MAC must contain at least two patients’ names, practices by allowing them to submit one and the date of service for each vaccination admin - claim for all of the Medicare beneficiaries istered must be the same. that received either pneumo

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