Medicare Compliance & Reimbursement

Secure the reimbursement you deserve.

With the Affordable Care Act ushering in a new emphasis on preventive care, providers must play their part in ensuring that Medicare beneficiaries receive the immunizations they need, when they need them. The Centers for Medicare & Medicaid Services (CMS) recently reiterated this responsibility in a weekly e-news bulletin to providers, calling vaccinations a “critical preventive health measure” and asking providers to ensure that patients are up-to-date on vaccines as recommended by the Centers for Disease Control and Prevention. 

In addition, the National Vaccine Advisory Committee (NVAC) released its updated standards for immunization of adults in September. NVAC recommends that providers: assess patients’ vaccination needs at each visit; recommend vaccines as needed; offer the vaccine or, if the provider does not stock the needed vaccines, refer the patient to a provider who does vaccinate; and follow up to ensure the vaccine was received.

Obstacle: Vaccines may be critical — and prevention a priority — but Medicare’s fractured coverage for immunizations does not facilitate compliance.

“CMS reminds all health care professionals that certain vaccines are covered by Medicare,” says the federal agency in their recent e-bulletin. The key word in that sentence is “certain,” as in, “not all.”

Refresher: Medicare Part B covers the following vaccines:

• Hepatitis B vaccine for patients at high or intermediate risk;
• Influenza virus vaccine;
• Pneumococcal vaccine; and
• Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition. For example, the tetanus-diphtheria (Td) vaccine is covered as part of wound management.

Under Part B, providers who administer the vaccine can submit a claim to the Medicare Administrative Contractor (MAC) for both the vaccine and its administration. 

Providers must turn to Medicare Part D, however, for coverage of other immunizations recommended for older adults, such as shingles (herpes zoster) or poliomyelitis. And, in many cases, providers cannot bill the Part D plan directly; rather, they must work with the patients and their Part D plans to obtain payment. 

Important billing alert: In February, CMS issued an important clarification via CR 8620. Specifically, this memo made clear that “any provider may furnish vaccines to hospice beneficiaries,” correcting an earlier CMS missive that the agency subsequently deemed “too restrictive.” That missive, CR 8098, effective October 1, 2013, had instructed contractors to deny claims if a hospice patient received a vaccination from anyone but the hospice provider. Any such claims denied in 2013 may be resubmitted, coaches CMS.

Moving forward, Medicare contractors will allow professional claims for vaccines under Part B (and vaccine administration) if you use modifier GW when the date of service falls within a hospice election.

Tip: If you are a physician’s office providing immunizations, make your payment policies clear to patients in advance. Good communication and coordination from your office prepares patients for the fact that Part D may not cover the full charge, depending on the “allowable charge” set by the plan. 

Web-assisted out-of-network billing is one way to go. Under this option, the physician submits out-of-network claims electronically to Part D plans using a web-assisted portal for vaccines he administers in his office. The physician submits the claim on behalf of the patient and agrees to accept Part D payment as payment in full. The patient pays only the appropriate deductible, copayment, coinsurance, or cost sharing directly to the physician. 

Doctor’s Orders

Remember that, unlike Part B claims for the influenza and pneumococcal vaccines, Part B claims for the hepatitis B vaccine must include the name and NPI of the ordering physician. That’s because the feds mandate that hepatitis B vaccine be given under a physician’s order with supervision. Standing orders can be used for both the influenza and pneumococcal vaccines.

E/M advantage: If you are a physician, don’t shortchange your practice when a patient presents for an evaluation and management (E/M) service other than preventive care and then opts to receive an immunization. In such a case, you may use modifier 25 to signal that the original E/M service was “significant and separately identifiable from the physician’s work of the vaccine counseling/administration,” coaches the American Academy of Family Physicians. 

For evaluation and management of a patient with diabetes, for example, you might report code 99213-25 with diagnosis code 250.00 in addition to the influenza vaccine and administration codes.

Striving to boost your patients’ immunization rates? Enlist the help of nursing and even office staff, offering training that helps them to recognize valid and invalid contra-indications to vaccinations. Office staff can also help track the minimum intervals permissible between vaccinations. 

The goal: Do not miss an opportunity to vaccinate.

Skilled nursing facility billers should remember that most Part B and Part D immunizations are not subject to SNF consolidated billing. 

Long-term care exception: A vaccine that is administered for therapeutic reasons rather than prevention, such as a tetanus booster given in conjunction with wound care, cannot be billed separately but rather is bundled in the Part A per diem.