Billing Flu Shots to Medicare and Commercial Insurance Companies
Since 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 depending on intramuscular vs. intranasal use, age of patient, formulation, preservative free, and split or live virus. If you are unsure of what code to use I suggest looking at the package information that came with the vaccine. Usually you can find the code on the packaging, and if you can’t find it in the documentation then call the supplier.
This is how most of our primary care practices bill for flu shots. Your situation may be different so make sure to check all the influenza vaccine codes 90654-90668 and use the appropriate code for the vaccine administered to the patient.
Commercial Insurance Carriers
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
Medicare
G0008 Administration of Influenza Virus Vaccine
Q203x Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Keep in mind that there are several codes for the flu vaccine when you bill for Medicare flu shots. The code you use is dependent on the manufacturer of the vaccine. Replace the code above with the correct vaccine code below.
Here is the list of the new Medicare Flu Vaccine codes for 2011. Choose the code based on the manufacture:
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)
Check out the short video we made about coding for the Medicare flu shot CLICK HERE
Pediatric Billing
If a child is under the age of 9 and has not previously received a flu shot, then usually two shots are given one month apart. After the initial series, in subsequent years only one shot is needed. When billing for the initial flu shot keep in mind that insurance should pay for both the initial flu shot and the flu shot given 30 days later. Be sure to follow up with the insurance companies if reimbursement is not issued for the second shot of the initial series. Typically these are denied but can be paid with a simple appeal or phone call correcting the denial.
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
Use the age appropriate codes as needed.
90657 Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use
Or
90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
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About Manny Oliverez - Medical Billing Company CEO
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Good morning Manny, I have a question I've been submitting flu shots to tricare and they have been rejecting because they want the national drug code, then sent them back with NDC but according to them thats not the correct one. Do you know what NDC would I use to bill for it? I also checked the websit cdc.gov could not find anything,
Help! thanks Mirna
Mirna, take a look at the package insert for the vaccine. The NDC number is specific to the manufacture, vaccine and strength. The proper NDC number for your vaccine should be on that insert. Use that number for your claim. One additional item to remember is that there is a specific format that you must follow when you put NDC numbers 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 on the package insert they are in 10-digit formats. Before entering the number into your computer system you must convert it to an 11-digit NDC or your claim will be denied.
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
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Hello. I am getting ready to do roster billing for our flu shots this year. I found the Q code that we need to use and the fee schedule for that. I am having trouble finding the Indiana injection fee schedule. Can you tell me where to find that?
Thanks!
Stephanie
The best place to start is the CMS website.
https://www.cms.gov/apps/physician-fee-schedule/o…
Through the website you can then narrow your search parameters to look for your Specific Locality or Specific Carrier/MAC. Just enter in the codes you are looking for in the HCPCS Code Box and search and this should bring up the requested information. Otherwise, depending on your local Medicare Administrative Contractor (MAC), go directly to their website and they should also have an available fee schedule for you search.
Can we bill Office visit along with flu shot?
Are you asking about billing a “nurse visit” 99201 or 99211 with your flu shot? If so, most insurance companies stopped paying those codes with vaccines. If the patient is coming in for an unrelated problem such as for a rash for example, you are able to bill a higher level office visit code with the appropriate diagnosis for that problem and then bill the flu vaccine and admin code with a V04.81. Check with your insurance carriers on their specific rules.
If my office wants to do a sort of flu express to administer the vaccination without having patients need to pay a copay, what diagnosis, procedure and encouter codes do use?
John sounds like you are going to have a flu clinic where you see a lot of patients at one time. We once had 400 patients come through in 2 hours at a flu clinic we held at our medical office. I worked for The Walt Disney Company in the past and know about crowd control and how to get people though a line fast. It worked well and the wait was only a couple of minutes.
For your clinic you still would bill these flu shots just as you would normally. Use 90471 (Immunization Administration) and 90657 (Influenza vaccine for children 6-35 months) or 90658 (Influenza vaccine for individuals 3 years or older) as appropriate for the patient’s age. For Medicare use G0008 for the administration code and the correct G code for the vaccine which is dependent on the manufacture (See above for codes). The V04.81 diagnosis typically goes with the flu shot.
Most insurance company no longer reimburse for a 99201 or 99211 so if they are just coming in for the flu shot you really don’t need to bill for the encounter. These encounter codes are the codes that usually cause the patient to have a copay. Billing just for the admin and vaccine should not cause the patient to have a copay. That has been our experience with our pediatric practice.
As always you should check with your insurance carriers for their specific billing, reimbursement and documentation rules.
if we do bill a 99213 along with 90658 and the 90471 will the insurance pay us less money on the office visit. i have been billing just the flu and the office code without the administration because sometimes insurances will decrease the payment considering it part of another procedure. what is your opinion on this
Hi Mary, typically we when we bill out an office visit 99213 with the flu vaccine 90658 and the admin 90471 our reimbursement rate for any of the services is not reduced. The multiple procedures rule does not usually apply to a vaccination. Have you checked your fee schedule with specific payers? What have the insurance representatives told you when you have called to follow up on this payment discrepancy? Please send us more information and we can try to point you in the right direction. Based on our experience, we have not had problems getting the proper (not reduced) reimbursement when billing out these 3 CPT codes together.
I am looking for some tips on billing for a Pediatric office. For comm'l carrier and of course BCBS Healthchoice/Medicaid. well child visits and etc.
Sheila we bill for a bunch of pediatricians. What specific questions do you have?
Hey Manny,
Quick question about the flu shots. Do you know if Medicare and the commercial insurance companies are requiring the NDC on all claims? I have been trying to research it but I am not able to find anything. I know you said Tricare does require it but I was wondering about everyone else. Thanks for your help!!!!
Yes Tricare does require NDC numbers. I am not sure if Medicare or commercial insurance companies require the NDC. I never looked into it. The reason it does not matter is since we had to include the NDC for Tricare in our computer system the NDC is now automatically picked up and sent with the other vaccine data to all the carriers.
Polly I am not sure if I am answering your question but once you include the NDC in the code tables of your practice management system everyone gets it. –Manny
Hi,
I work for a hospital and was told that we can bill a level 1 or 2 for just a flu vaccine. Is that correct? Seems a little unreasonable for just a flu vaccine without having anything else.
Rudy, I want to understand clearly, are you saying that if a patient comes into your hospital just for a flu shot and no other service is performed the hospital administration is telling you to bill up to a level 2 visit along with the flu shot? How do you know if its a level 1 or level 2? Are you looking at the chart notes? Level 1 can be for a nurse and level 2 for a physician, NP or PA. Sounds like you are just suppose to pick one regardless?
That said, if the only service you are providing is giving a flu shot, at best you can only bill a level 1 but even that is not billed any more these days. The administration of vaccine code 90471 or G0008 for Medicare is about all you can bill allong with the influenza vaccine codes.
Is there anything else to this story? Are they telling you why? What diagnosis are you using for the E/M visit? Is it different?
I know I am asking more questions but this seams very odd and interesting. –Manny
Hello, Manny
What is the right CPT code for flu shot for medicaid patients?
Usually you can bill Medicaid as you would commercial insurance. That said, each state can have their own rules on how they want the flu vaccine billed. Additonally, most states have a Vaccines For Children (VFC) program that provides the influenza vaccine at no cost to the patient. You will have to check with your states Medicaid. You should be able to find the billing information on their website.
Hope this helps –Manny
Hi Manny,
I have just started an online Medical Coding and Billing course. I am very excited to begin my new career. If you have any advice for a newbie it would be appreciated! I found you on twitter and enjoy reading you comments. All my books teach the ICD – 10 Codes. Thank you!
Susan good people are always going to be needed in medical billing and coding. With all the new rules and changes the government and insurance companies will be implementing over the next few years and the transition to ICD-10, I believe there will be job security in our field. The key is to make sure you keep studying and gaining experience. We have several team members here at Capture Billing that have 10-20+ years of medical billing and coding experience and hardly a day goes by where we all don’t learn something new because of the ever changing world of healthcare. Our people read a lot, get ongoing training and have access to great resources in order to do their jobs properly. You really must have a good attention to detail to succeed.
Now taking classes is a great start, but only a start. It will take you another good year or so in a medical billing position, getting hands on experience, to really be able to understand all the concepts. The learning will then continue throughout your career. Remember, Attention to Detail.
Best wishes to you –Manny
We started administrating vaccines for children [Hep A 90633, Diphtheria Tetanus Toxoids 90700, Rotavirus 90680, MMR 90707, etc. As I read about the admin codes to use, they become confusing and sometimes I feel there is information missing or out of sequence – i.e., if I bill for the CHCUP 99382 with the Hep A and the MMR, maybe the Rotavirus, can you address me where to read how to bill or give me an example. Thank you very much!
Well Lal there are a couple of ways you can bill your well child visit with immunizations.
You can bill using the vaccine admin codes 90471 and 90472 as follows:
99382
90471
90472 x2
90633
90707
90680
You can also bill using 90460 and 90461 as follows:
99382
90633
90460
90707
90460
90461 x2
90680
90460
So what is the difference? This is what CPT says . . .
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)
Use the administration codes that best describe what you are doing at your practice. Make sure you document well.
We usually use a diagnosis code of V20.2, Routine infant or child health check, which includes developmental testing of an infant or child, age appropriate immunizations, routine vision and hearing testing. That ICD-9 code would go with all the CPT codes.
It would also be appropriate to use the individual vaccine ICD-9 codes with the vaccines instead of V20.2. The claim for the vaccines would look like this:
90633 V05.3 Need for other prophylactic vaccination and inoculation against single diseases, viral hepatitis
90707 V06.4 Need for prophylactic vaccination and inoculation against combinations of diseases, measles-mumps-rubella [MMR]
90680 V05.8 Need for other prophylactic vaccination and inoculation against single diseases, other specified disease
Check with your insurance carriers on how they would like these visits billed. Each may want something a bit different.
Let me know if this was helpful or if you have more questions. –Manny