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Medicare Codes for Flu Shots: Q2035, Q2036, Q2037, Q2038

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New Medicare Influenza Vaccine Q Codes for 2011

Medicare Flu ShotsEffective January 1, 2011 the Centers for Medicare & Medicaid Services (CMS) will no longer recognize and no longer reimburse CPT Code 90658 Influenza Virus Vaccine, Split Virus for flu shots. CMS has established five separate influenza vaccine HCPCS codes to distinguish between the brand-names of influenza vaccines for governmental tracking purposes. Make sure to use these new codes in your medical billing.
[pullquote]New Medicare codes distinguish between vaccine brands for Medicare [/pullquote]The HCPCS code G0008 Administration of Influenza Virus Vaccine must still be used for the administration of the flu vaccine for Medicare patients.

The New HCPCS Medicare Flu Vaccine Codes

Q2035 Afluria Vaccine:

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)

Q2036 Flulaval Vaccine:

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)

Q2037 Fluvirin Vaccine:

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)

Q2038 Fluzone Vaccine:

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)

Q2039 NOS (Not Otherwise Specified) Vaccine:

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)

Reimbursement Rates

The national average for Medicare payment allowance may vary by geographical location and you will need to check the CMS Fee Schedule for your correct reimbursement rate. HCPCS codes Q2035 & Q2039 do not have national payment limits and will be determined by the local Medicare carrier.

National allowables for the Q2036 is $7.439, Q2037 is $13.253, and Q2038 is $12.593.

Please refer to the CMS Physician Fee Schedule at: http://www.cms.gov/PhysicianFeeSched/01_overview.asp

Additional information can also be found at: http://www.cms.gov/MLNMattersArticles/downloads/MM7234.pdf

For a video on Medicare flu shot coding go to:  What are the Medicare Flu Shot Codes

Medicare Billing Services

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82 Responses to “Medicare Codes for Flu Shots: Q2035, Q2036, Q2037, Q2038”

  1. Nisha says:

    Is a flu vaccine Q2037 can be provided twice in one flu season?

  2. Larry Turnipseed says:

    Thank you for helping out, superb information.

  3. Dettor says:

    2011 Medicare Codes for Flu Shots:Q2035, Q2036, Q2037, Q2038 was saved as a favorite :), I like your blog!

  4. Tiffany says:

    A post somewhere had said to use the administration code 90471 for without an office visit charge, but I didn’t think so. Thank you for your reply.

    • You can use 90471 with the flu vaccine but not for Medicare. What insurance companies do like anymore is a 99211 with a 90471 and the flu vaccine. The 99211 rarely pays. But billing without an office visit is fine.

  5. Tiffany says:

    Hi, is there a different coding process for Medicare patients that come in just for the flu shot vs the Medicare patients that comes in for flu shots and an office visit charge?

    • Tiffany if a Medicare patient just comes in for the flu shot you should code G0008 for the administration, the appropriate Q code for the vaccine and V04.81 as the diagnosis code.

  6. Karoline Winnewisser says:

    whats your facebook page?

  7. Carlo Raybould says:

    Hi-ya, This 2011 Medicare Codes for Flu Shots:Q2035, Q2036, Q2037, Q2038 article is charming, I really like this material
    I’d really like to know if you have an RSS feed so I can find out when your site post more posts on the blog

  8. Beny says:

    Do I need to write the ndc number to bill Medicare for the flu shot?

    • Yes, you need to send the NDC number with all claims. Remember there is a specific format that the number must be in to be accepted. You will find the NDC in the package insert for the vaccine.

  9. Kim says:

    Do you use the 90471 or G0008 for the administration code for Tricare?

  10. beth says:

    Hi there, If a patient has commercial insurance primary so therefore we bill with the commercial flu codes/admins, and there is a balance left to be forwarded to the secondary which is Medicare… Then would we need to change the codes to Medicare codes first and then submit? Our pricing is different and so it gets complicated to change them after primary has paid. The only info I can locate is regarding the consult codes which they have specific exceptions and options. But I'm curious about the flu shots. Please help :0)

    • Start with the CMS website at <a href="http://www.cms.gov” target=”_blank”>www.cms.gov and you can search for many terms under “secondary payer Medicare”. The overview page is a great starting place with some general information. The FAQ sheet also provides additional basic information: https://www.cms.gov/MLNProducts/downloads/MSP_Fac…. There are also SEVERAL manuals available on the CMS website for Medicare Secondary Payer rules but basicly when Medicare is secondary you will need to send them the apprpriate G code. And yes it can get complicated.

  11. [...] The analysis of any medical billing or coding question is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies (as well as coding itself) are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly.Source: capturebilling.com [...]

  12. jamie says:

    DOSE CAREFIRST BCBS OF MD WILL PAY FOR CPT Q2039? THEY ARE STATING THAT, THIS CPT IS NOT LISTED UNDER THERE FEE SHEDULE. WHAT DO WE HAVE TO DO?

  13. MDL says:

    So what's the difference between all of these flu shots? And why are only some of them covered by certain types of insurance?

    • The new Q codes were setup by Medicare to identify the manufacturer of the influenza vaccine for reporting purposes. The only “insurance” this effects is Medicare. The Q codes should not be billed to a commercial insurance company. Usually insurance covers flu shots but with people and employers choosing cheaper health insurance policies to save money we have seen more flu shots going towards insurance deductibles.

  14. ANNA says:

    Thank you Manny, your reply to questions regarding Q codes are very clear and very well understood. I will be billing Dialysis for the first time for both commercial Insurance and Medicare, can you please give me an insite on how to approach this new project. Thank you.

    • Anna you will need to do lots of research. This is what I would do:

      1. Get on Google and start searching on how to bill for dialysis. Now you will need to make sure that the information is correct because there is a lot of info that may not be right on the web.

      2. Go to insurance company websites and see if they information on how they want dialysis billed. This may vary from insurance company to insurance company so check them all out.

      3. Next go to the American Society of Nephrology website at http://www.asn-online.org/ and see if they have any articles on billing.

      Thant should get you started.

  15. dainapeter says:

    If you’re not using HCPCS codes correctly, get your pen ready for major paybacks. With HCPCS codes making the top error reporting lists, be prepared for auditors to hone in on your equipment and supply coding. Penalties for double billing on supply and drug codes can run into the hundreds of thousands.

  16. Julia says:

    Do the Q codes require us to bill with a NDC code? My billing system is asking for one, I put the NDC code in and he claims were returned by medicare stating NDC code invalid.

    • Manny Oliverez says:

      Julia we send ours in with the NDC number. There is a specific format that you must follow when you put it into your computer system. NDCs are in a 11-digit format and are usually seen in a 5-4-2 format. For example: 99999-9999-99. Sometimes, just to confuse things I believe, they are in 10-digit formats. Before entering the number into your computer system you must convert it to an 11-digit NDC.

      Use the following methodology to convert your NDCs from 10-digits to 11-digits:

      If 10-digit NDC format is: 4-4-2 9999-9999-99
      Then add a zero (0) in: 1st position 09999-9999-99
      Report NDC as: 09999999999

      If 10-digit NDC format is: 5-3-2 99999-999-99
      Then add a zero (0) in: 6th position 99999-0999-99
      Report NDC as: 99999099999

      If 10-digit NDC format is: 5-4-1 99999-9999-9
      Then add a zero (0) in: 10th position 99999-9999-09
      Report NDC as: 99999999909

  17. JANICE says:

    WE ARE GIVING INFUSIONS IN OUR OFFICE THE INFUSION IS ERTAPENUM AND COMES WITH 100ML NORMAL SALINE I CANNOT FIND A HCPCS CODE FOR THE 100 ML I CAN FIND A CODE FOR 250CC PLEASE HELP………. jANICE

    • Manny Oliverez says:

      If you look at the wording at in the code book often you will see that the is says up a certain amount. Not always however. What is the code you are using? The one I found is J1335 for up to 500mg.

  18. Amy says:

    I work for an Endocrinologist in NYC. I'm his OM and Biller. It's hard to keep up w/all the changes. He is also licensed as an Internist and has a small, basic clinical lab in the back. I bill most codes w/the Medicare required QW separately as the regulation states, for the Medicare patients he does NOT Accept assignment on. My confusion is…do I need a modifier 25 for the flu shot because it is a separate procedure from the patient's follow-up Diabetic visits. Do I bill it with the clincial lab codes OR with the E/M codes? PLEASE ADVISE. It is much appreciated.

    • Manny Oliverez says:

      Amy, typically the flu shot is never billed with a modifier – neither the -25 nor the –QW modifier. We have submitted claims to Medicare for the Q codes with no modifier and have been paid by our local Medicare carrier. Also the flu shot is typically billed out with the office visits – not the lab, as the flu shot is a vaccine that does not require a test. Additionally the office staff should be billing out for the Administration of the Vaccine G0008.

      However, since you are NOT accepting assignment, that means you are a NON PAR provider. Medicare will not reimburse you and you cannot bill the member because you would not be considered an approved lab and cannot bill the member unless the member signed the appropriate ABN that makes them aware that you are non par and they accept financial responsibility for all charges.

      The question that we have for you is , if you are non par and don’t accept assignment why are you billing Medicare in the first place?

  19. JESS says:

    WHEN USING THE 90662 WHAT IS THE Q CODE THAT IS NEEDED OR DO WE JUST USE A G CODE FOR THE FLU HIGH DOSE?

    • Manny Oliverez says:

      Jess as far as I know there is no Q code that equates to 90662. You should bill G0008 for the admin and 90662 for the high dose flu vaccine. You may want to go to your local Medicare carrier's website to see if they have specific billing information on this topic.

  20. Barb says:

    Did Medicare change drug code for pneumonia and the admin or is it still 90732 and G0009?

    • Manny Oliverez says:

      I beleive the code is the same and did not change. Here is a bit more info that may help.

      Bill for the Pneumococcal Vaccine with the following applicable codes plus the Administration of the vaccine G0009:

      • 90669 Pneumococcal Conjugate Vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use

      • 90670 Pneumococcal Conjugate Vaccine, 13 valent, for intramuscular use

      • 90732 Pneumococcal Polysaccharide Vaccine, 23 valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use

      o Use diagnosis code V03.82 for just the Pneumococcal vaccination visit
      o Otherwise use diagnosis code V06.6 when the purpose of visit was to receive both pneumococcal and seasonal influenza virus vaccines.

  21. [...] it is now flu season I have been getting a lot of questions on how to bill flu shots to commercial insurance companies and Medicare. The codes used for a particular vaccine will vary [...]

  22. leticia says:

    I used the g code and the q code but medicare denied saying that it wasnt medically necessary? I used v0481? was I should I have used a different dx code???

  23. Nancy says:

    Can you still bill 90658 administration code for commercial carriers? I know Medicare moved it to a Q code after Jan. 1, 2011, but I am confused over the commercial carriers. I also see the cpt code 90471 for commercial administration.
    All of our patients are adults.

    • Nancy 90658 is a Influenza Vaccince code with 90471 being the code for administration.

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

      Also check out our post on billing flu shots CLICK HERE

  24. Cheryl says:

    Actually could you tell me the correct way to bill the flu shot for both Medicare & other insurances? Thanks.

  25. Cheryl says:

    Do you use the Q codes for commercial insurance companies as well?

    • capturebill says:

      Cheryl the Q codes are only for Medicare (at this point).

      • Cheryl says:

        Thanks. I understand the Q codes & the G0008 that goes with it are for Medicare only. Do you know what or where to find the codes for all other insurance companies? I know in place of the G0008 you use 90471. Thanks.

        • Manny Oliverez says:

          The CPT codes for submitting to commercial insurance companies have not changed. The Influenza code range is 90654-90668. Look up those codes and choose the appropriate one for your situation. For the most part the primary care practices we service are using 90658.

  26. medical billing and says:

    This was agreat article keep it up!

  27. MedBlits.com says:

    American Academy of Ophthalmology Calls for Medicare Physician Pay Fix That ……

    American Academy of Ophthalmology Calls for Medicare Physician Pay Fix That Assures Patient Access to Quality Specialized Medical Care MedPAC Proposes to Shift Cost to Medical SpecialtiesSAN FRANCISCO, CA and WASHINGTON, DC — (Marketwire) — 09/21/11 …

  28. jimi says:

    I have many patients with Medicare replacement plans such as Humana. When it is a MCR replacement plan do we use the Q and G codes for these?

  29. Dawn Sorokey says:

    We are a hospital based article 28. We bill both professional and technical for most office visits, xrays etc. My question is, how should we bill medicare for the flu and pneumos. Normally we would bill part A.

    Please help.

    Thanks, Dawn

    • Dawn, we work with physician offices and bill only Medicare Part B so I am unsure of any nuances there may be for you in your situation. One consideration would be how your software and the clearinghouse handles the electronic transaction for Part A vs. Part B claims. All your claims may be setup to automatically go to Part A. You may have to, on a claim by claim basis, send the claims to Part B. There should be a way to do that in your computer system. You should also call your local Medicare carrier for help on where to send the claim and contact your tech support if you have questions on how your computer system is setup to submit your claims. Have you billed Medicare Part A and received denials?

  30. diep says:

    Doctor sees a patient and also gives a flu shot the same day, can I bill Medicare 3 cpt codes at once and do I need to use any modifier?

    cpt, flu shot (Qxxx) and G0008 '

    Thank you

  31. Peggy says:

    Can you bill an E&M for the phyician visit and Q with the G code?

    • You can bill an E&M code along with the Medicare flu shot codes if the reason for the visit is for something other than just coming in for the vaccine. The diagnosis code associated with the visit must be different than for the shot.

      • diep says:

        I billed medicare flushot and G0008 with modifier 25, i don't get paid due to a required modifier is missing. I used modifier 25.

        • Manny Oliverez says:

          Modifier 25 is for E&M codes. No modifier is required when billing G0008 and the flu vaccine for Medicare. You may have gotten an inappropriate denial.

  32. Melissa Nguyen says:

    Would you use G0008 & 1 of the Q codes for a flu shot given to a pt with a Medicare Advantage Plan? For example Medicare Blue or Humana.

  33. Connie says:

    Hello,

    What is the difference between those flu vaccines, Afluria, Flulaval, Fluzone, Fluvirin, that cause the reimbursement rate to differ?

    What does Medicare allow for G0008?

    Can I use injection code 96372?

    Thank you very much. Your website is very helpful.

    • Connie here is what I have come up with. Hope it answers your questions.

      The flu vaccine reimbursements are based on 95% of the Average Wholesale Price (AWP). Please refer to this CMS article which explains why there is a variance in reimbursement: http://www.cms.gov/MLNMattersArticles/downloads/M…. Although the article does not discuss “why” there is a difference in the AWP, it does explain how they base their reimbursement. I can only assume that the difference must be based on material or cost from the manufacturer.

      The allowable for the G0008 may vary based on location but is about $25. Please check with your local Medicare Administrative Contractor (MAC) for specific locality reimbursement or you can also check the physician fee schedule for your area: http://www.cms.gov/apps/physician-fee-schedule/li

      If you are billing for a flu vaccine then no you cannot use the 96372 which is for a therapeutic injection and not for the administration of the influenza vaccination.

      For a Medicare patient use the G0008. For a non Medicare patient use the 90471.

      Additional useful links/resources

      Educational resources:
      http://www.cms.gov/MLNProducts/Downloads/Flu_Prod

      Medicare Flu billing instructions and introduction of new HCPCS codes:
      http://www.cms.gov/MLNMattersArticles/downloads/M

      Medicare Quick Reference guide:
      http://www.cms.gov/MLNProducts/downloads/qr_immun

      • David Vaxmonsky says:

        The difference with the reimbursement rates is that the higher rates correspond to the preservative-free prefilled syringes, which have a higher acquisition cost.

  34. Manny Good morning I have questions, regarding flu shots is cpt 90658 will no longer be used for all other inusurances also? Do you know what cpt code do i use for flu shot 65 and over? I would appreciated if you let me know

    Thanks

    Mirna

    • Mirna you can use 90658 for commercial insurance companies. For Medicare you would use G0008 for the administration of the flu shot and one of the new Q codes for the vaccine given. The Q code will vary from practice to practice depending on who the manufacturer is of the flu vaccine. For example, if you use Fluzone the you would bill:

      G0008 Administration of Influenza Vaccine

      Q2038 Fluzone Vaccine

      Hope this helps.

    • KIM says:

      Actually you are to use 90662 for the high dose vaccine and use the Q-codes for standard doses.

      Hope that helps.

      • Thank you Kim for the additional info. CPT 90662 is for the Fluzone High-Dose Vaccine which has 4 times the antigen of the regular vaccine. It was specifically developed for people 65 years of age and older to generate a bigger immune response to better protect them from the flu. The Medicare reimbursement is around $29 but check with your local Medicare carrier.

        Keep those comments coming Kim!

    • Amber says:

      Tricare states that cpt code 90658 is currently not priced by them. If this code is used for billing, the claim must be billed with the NDC rate.
      I talked to a rep today and he wasn't sure but thought they may go back and audit all 90658 from January 1, 2011 and try and recoup their payments.

      • Manny Oliverez says:

        I just read a notice on a Tricare website dated October 20, 2011 that said that Tricare will be following the latest CMS billing guidelines for the 2011-2012 flu season. They have made the change retroactive back to January 1, 2011. It states as follows:


        CPT code 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older for intramuscular use) is currently not priced by TRICARE®. If this code is used for billing, the claim must be billed with the National Drug Code (NDC) number and it will be reimbursed at the NDC rate. If there is no NDC on the claim, it will be denied. If the 90658 is denied and an Q-code is appropriate, a corrected claim can be submitted.

        So in other words the claim will be paid based on the manufacturer, since the NDC identifies the maker of the vaccine. If there is no NDC number, the claim now will be denied. This is as of 10/20/11 per Tricare but they are going back to 1/1/11. So based on what your rep stated to you, if claims were sent earlier this year without an NDC number and Tricare paid those claims then they would ask for their money back. I can see where the rep would have come up with that. However, Tricare has required the NDC number for quite some time and has denied claims if the NDC number was not submitted.

        Please post if you have more info or you hear more on this subject. We are checking closer too. Thanks!

  35. Valuable post, I'll go along with your blog often.

  36. Barb Jones says:

    Dear Mr. Oliverez,

    If we charge $19.80 for Administering the Vaccine and $12.59 for the vaccine…what is our allowable amount how high can we go? I am new to all this and have been asking so many questions and getting nowhere, hope you can help!

    • Barb —

      I don't have enough information from your post to help you. If you are asking what is the allowable charge that the insurance company will reimburse your for, well that depends on your contract with the individual carrier. If you are asking how much you are allowed to charge, then my answer would be you can charge anything you want to because what is not allowed by the insurance company will not be paid and you will have to write it off. In some cases such as Medicaid there may be an amount you are required to charge but that can vary from state to state. Please feel free to give me more info so I can better help you.

      Manny

  37. Susan A. says:

    What is Medicare Q code for patients < than 65 years of age??

  38. Susan there are cases where a Medicare recipient is under the age of 65. Unfortunately we have not had to bill flu vaccine for a patient meeting that criteria. If we did we would use the Q codes.

    I would check with your local Medicare carrier for their billing policies.

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The analysis of any medical billing or coding question is dependent on numerous specific facts -- including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies (as well as coding itself) are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly.

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