Medicare Compliance & Reimbursement

CDC issues warning that this year's flu season is already off the charts.

Reports suggest that this flu season is ramping up to be in the record books. It's no fun getting sick, but it can be even less fun to code for influenza vaccinations. This important preventive measure is one of the most valuable services clinicians can offer their patients - but understanding the how, what, and when of flu vaccine coding is crucial to avoid a rejected claim.

In the news: The Centers for Disease Control and Prevention (CDC) issued a Health Advisory warning on Dec. 27, 2017 to U.S. providers about the onset of "influenza A(H3N2)" and the health ramifications of its spread across the nation. The CDC issuance suggests the virus is on the rise, impacting more patients and causing more hospitalizations.

Due to the increased A(H3N2) activity, the CDC recommends patients and providers combat against the strain this season with vaccinations. "The more people who get vaccinated, the more people will be protected from flu, including older people, very young children, pregnant women, and people with certain long-term health conditions who are more vulnerable to serious flu complications," the CDC guidance suggests.

Read the CDC Health Advisory at: https://emergency.cdc.gov/han/han00409.asp.

Take a Look at the Seasonal Parameters

Influenza vaccinations are given per flu season and not by year, so Medicare beneficiaries can reasonably receive more than one booster a year as long as the shot is medically necessary and the documentation is in the notes, indicates Michelle Coleman, CPC from Part B MAC NGS Medicare's provider outreach and education department in a web presentation on the subject. "You can receive more than one flu vaccination per year," she explains. "The way we pay it is per season."

Time frame: According to CMS, payments for influenza vaccinations run from Aug. 1 to July 31 each year. For example, you could administer a flu shot in February 2018, which falls under the 2017/2018 flu-season limits, and your patient could come in again in October of 2018 for another because that is considered part of the 2018/2019 flu season.

Claims Overview: Single claims for the various flu vaccines must be submitted electronically to your Medicare Administrative Contractor (MAC) on the CMS-1500 form. Starting last July, NGS Medicare stopped accepting handwritten influenza claims and will now send handwritten submissions back to the provider, its guidance suggests. "Only the signature blocks on the CMS-1500 claim form are allowed to contain handwriting (Items 12, 13, & 31)," the NGS Medicare webinar materials note. Check with the MAC in your jurisdiction for clarification on its particular guidelines for claims submission to avoid denials.

However, there are always exceptions to the rule with Medicare submissions. Currently, there are ten exceptions under the Administrative Simplification Compliance Act (ASCA) that allow you to bypass the electronic form and submit a paper one. The exceptions and the explanations behind them can be found in Chapter 24, Sections 90-90.7 of the Medicare Claims Processing Manual with many of the special cases related to practice size, mass immunization issues, or reduced vaccination claims.

Find a quick review of the ASCA exceptions at: www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/ASCASelfAssessment.html.

Look At These Updated CPT^® 2018 Options

In the midst of 2017-2018 influenza season this year, 90682 (Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use) joins 90756 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage, for intramuscular use) as new additions to CPT^® 2018, "continuing the revisions started last year to focus CPT^® descriptors on dosage while discontinuing age specificity," according Jan Blanchard, CPC, CPMA, a consultant at Vermont-based PCC.

Technically, neither code is new. Code 90682 made its appearance on the AMA website on July 1, 2016, and became effective January 1, 2017, but 2018 marks the first year it will appear in the CPT^® book. Keep in mind that this code appears out of numerical sequence in the CPT^® book, appearing between codes 90674 and 90673 because of proper placement in the "Vaccines and Toxoid" section of the code set.

Important: Some payers started accepting 90756 - known by its trade name, Flucelvax - on July 1, 2017. If your payer does not recognize the code, you can use 90749 (Unlisted vaccine/toxoid) or HCPCS code Q2039 (Influenza virus vaccine, not otherwise specified) in its place. But be wary of how you use Q2039, warns Coleman. "To use this code [Q2039] you really need to make sure there is absolutely no other code available. Otherwise your claim will be denied," she cautions.

Keep In Mind These Basic Flu Vaccine Coding Basics

Remember, you will need to report three codes for each vaccination claim: one administrative code, one vaccine code, and one diagnosis code. "The codes vary based on the drug manufacturer, so you'd bill according to which code is applicable to your office," advises Coleman.

Consider these three tips on proper codes and age requirements when filling out your influenza vaccination claims based on the documentation of the service:

Administration and vaccine:

• ICD-10: You will report any immunization, and that includes all influenza vaccinations, with Z23 (Encounter for immunization) as your diagnosis code.
• Age: The patient's age also factors into the picture, so before you write up your claim, it's a good idea to check the age of your patient against the CPT^® code you'll be using.

Pricing: The Medicare Part B payment allowance is "95 percent of the average wholesale price (AWP), and the pricing is updated quarterly," says Coleman. However, "administration payment allowances are updated annually on January 1," advises MAC Palmetto GBA's online guidance. Administration rates are in effect from Jan. 1 to Dec. 31 of each calendar year.

According to CMS data, the CPT^® 2018 additions will garner $46.313 from Medicare for 90682 and $22.793 for 90756.

Here is the link to the most up-to-date 2017/2018 influenza vaccination pricing: www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html.

Nonparticipant facts: Nonparticipating providers must take assignment on the claim as well, and Coleman recommends that they let their patients know ahead of time to avoid the administrative fee charged by nonparticipants. "Let your patients know upfront if you are a nonparticipating provider," she says. "Because there are many options for beneficiaries, where they don't have to lay out an additional fee."