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Medicare: Video Helps Explain Influenza Vaccine Q Codes

Health Insurance Companies Process 1 in 5 Claims Wrong

Coding for Medicare Flu Shots Q2035, Q2036, Q2037, Q2038

Medical Billing Guidelines

Watch the coding for Medicare flu shots video and learn that as of January 1, 2011 if you bill Medicare CPT Code 90658, for the Influenza Virus Vaccine, you will not get paid. Medicare has established five separate influenza vaccine Q Codes to distinguish between the brand-names of influenza vaccines.

The HCPCS code G0008 Administration of Influenza Virus Vaccine must still be used for the administration of the flu vaccine for Medicare patients.

What are the New Influenza 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)

Additional information direct from Medicare on medical billing for influenza vaccines can be found at: http://www.cms.gov/MLNMattersArticles/downloads/MM7234.pdf

is a 20 year veteran of healthcare having managed medical practices. He advises medical practices, physicians and practice administrators on how to run their practice and manage their medical billing and revenue cycle management. Manny speaks, blogs and makes videos at www.CaptureBilling.com, a blog that is tops in the medical billing and coding field. READ MORE

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11 Responses to Medicare: Video Helps Explain Influenza Vaccine Q Codes

  1. I am new to a Physicians office and am having to bill for 99204; 36415; 85025; 80053; 80061. Should I bill the 8 codes with or with the QW modifier to Medicare? Please Help!

    • You only need the QW modifier for the CLIA waived tests done in the office. No need to put the QW in the office or the venipuncture.

      However I don’t believe the test you listed are not waived tests and thus a QW modifier is not appropriate. Are you doing these in the office? Sending them to an outside lab?

      85025 Complete Blood Count, with differential WBC
      80053 Comprehensive Metabolic Panel
      80061 Lipid Panel

  2. Medicare is requiring a modifier for flu vaccine Q2035. I cannot find which modifier to code with this vaccine. The rejection code if CO4. From what I read it appears the modifier SE should be used but I cannot find verification of this – can you help me?

    • Sanya —

      The CPT code for the influenza vaccine can vary by manufacture. There are several that produce the vaccine including, GlaxoSmithKine, Sanofi Pasteur, MedImmune, Protein Sciences Corp, bioCSI, Novartis and ID Biomedical.

      Their vaccines are marketed under the brand names Afluria, Fluarix, FluLaval, Fluvirin, Flucelvax, Flublok, Fluzone and Fluzone High-Dose

      Then you need to know if the vaccine is preservative free becasue there is a different if it is. On top of that is the vaccine trivalent or quadrivalent, protecting against 3 or 4 strains of influenza.

      Based on you the info you provided and given that pre-filled syringes are usually preservative free, it could be one of two CPT codes listed below.

      90656 Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
      90686 Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use

      The diagnosis code we typically use is V04.81, Need for prophylactic vaccination and
      inoculation, Influenza.

      Also don’t forget that you may need the NDC number to get paid by some insurance companies. You should find that in the package insert for the vaccine. Use the 11 digit format. Sometimes they only provide 10 digits and you have to convert it to 11 by adding a zero in the appropriate location in the code.

      Hopefully this info will point you in the write direction. Make sure to check your coding books and with your insurance carriers on how they want the vaccine billed.

  3. I have submitted G0008 and Q2038. They also had a 99214 visit for different reason. Medicare is not paying G0008 with reason codes COB15 and M80. I never had a problem with getting paid for administration before. Pleas help.

    • We frequently bill problem visits with the flu vaccine and administration and have not had any issues getting reimbursement for all three line items you’ve indicated above. Did you append modifier -25 to the office visit? If not we recommend you resubmit the claim with the 99214-25. This should alleviate the reimbursement issue. Also make sure that the referring physician is indicated (even for our family practice we have to put in the referring physician – we use the actual PCP even if it is one of our own doctors) because otherwise the claim will be denied for missing/invalid information.

  4. When billing Medicare we use the CPT G0008. Should we also use the CPT codes 90471 without office visit and 90460 visits with office visit?

    • Diane thanks for your question. There is only one administration code for Medicare flu shots and that is G0008. CPT Code 90471 or 90460 would not be used for the flu admin code for Medicare. Also just an FYI, 90471 may be appropriate without an office visit but 90460 may not be appropriate even if there is an office visit.

  5. Dear Mr. Oliverez,
    I billed medicare for Flu vaccine with Q2036 and G0008. It was rejected with remarks M25 and N29.
    I use fluval for vaccination. I have givenMore than 250 vaccinations. please advise

    • Dr. Venkatesh
      Our practices have been using those same codes, G0008 and Q2036 with V04.81 and are getting paid by Medicare. I looked up the denial reason codes and they really don’t make much sense for a flu shot. What ICD-9 code are you using? Looks like you will have to have your billing people call Medicare and find out what is going on.

      M25 Payment has been adjusted because the information furnished does not substantiate
      the need for this level of service. If you believe the service should have been fully
      covered as billed, or if you did not know and could not reasonably have been expected
      to know that we would not pay for this level of service, or if you notified the patient in
      writing in advance that we would not pay for this level of service and he/she agreed in
      writing to pay, ask us to review your claim within 120 days of the date of this notice. If
      you do not request a appeal, we will, upon application from the patient, reimburse
      him/her for the amount you have collected from him/her in excess of any deductible
      and coinsurance amounts. We will recover the reimbursement from you as an
      overpayment.
      Note: (Modified 10/1/02, 6/30/03, 8/1/05)

      N29 Missing documentation/orders/notes/summary/report/chart.
      Note: (Modified 2/28/03, 8/1/05) Related to N225

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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. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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