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How to Bill for Adult Immunizations

Hough preventive care, patient convenience,and expansion of services are good reasons for providing vaccinations to adults , adequate reim-bursement offers an additional incentive. Whenvaccination services are billed appropriately, privateinsurance companies generally reimburse for adultimmunizations, and Medicare covers routinely prescribed Adult Immunizations . By following somesimple guidelines, you can minimize administrativehassles in billing for these insurance coverage of Adult vaccines Private Insurance Most private health insur-ance plans cover the cost of providing recom-mended vaccines to your patients. If your patientsdo not currently have health insurance, refer themto learn more about theirhealthcare coverage options. Medicare For patients 65 years of age or olderenrolled in Medicare, Medicare Part B covers the cost of influenza and pneumococcal vaccines,as well as hepatitisB vaccine for per-sons at increasedrisk of hepatitis with aMedi care Prescrip-tion Drug Plan (Part D) or who areenrolled in a Medicare Advantage Plan (Part C)that offers Medicare prescription drug coveragemay also have coverage for addit

reminders, standing orders, and other methods of standardizing your o[ce operations, can substan - tially reduce the costs of administering vaccinations ... When administering inZuenza, pneumococcal, and/or hepatitis B vaccines, you may bill for addi-tional reasonable and necessary services. For

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Transcription of How to Bill for Adult Immunizations

1 Hough preventive care, patient convenience,and expansion of services are good reasons for providing vaccinations to adults , adequate reim-bursement offers an additional incentive. Whenvaccination services are billed appropriately, privateinsurance companies generally reimburse for adultimmunizations, and Medicare covers routinely prescribed Adult Immunizations . By following somesimple guidelines, you can minimize administrativehassles in billing for these insurance coverage of Adult vaccines Private Insurance Most private health insur-ance plans cover the cost of providing recom-mended vaccines to your patients. If your patientsdo not currently have health insurance, refer themto learn more about theirhealthcare coverage options. Medicare For patients 65 years of age or olderenrolled in Medicare, Medicare Part B covers the cost of influenza and pneumococcal vaccines,as well as hepatitisB vaccine for per-sons at increasedrisk of hepatitis with aMedi care Prescrip-tion Drug Plan (Part D) or who areenrolled in a Medicare Advantage Plan (Part C)that offers Medicare prescription drug coveragemay also have coverage for additional vaccines likezoster and Tdap.

2 Additional information is avail-able at Medicaid Vaccine coverage for Medicaid beneficiaries varies by state. Contact your StateMedicaid Agency (contact information available at ) for more : A Step-by-Step GuideImmunization Action Coalition b:How to bill for Adult ImmunizationsAdapted and updated by immunization Action Coalition, courtesy of the American College of Physicians, Part B covers the cost of influenza and pneumococcal vaccines, as well as hepatitis B vaccine for persons at increased risk of hepatitis coverage for Medicaid beneficiariesvaries by state. Contact your State Medicaid Agency for more section summarizes Medicare Part B regula-tions in plain English and provides charts to helpyou properly code vaccinations for both Medicare and third-party billers.

3 It also explains how innova-tive bill ing techniques, when combined with chartreminders, standing orders, and other methods ofstandardizing your office operations, can substan-tially reduce the costs of administering vaccinationsin your office. Additional information on improvingimmunization rates in your practice is found inIAC s Strategies to Improve Adult Vaccination Cover-age, available ,as well as on the immuni -zation websites for theAmeri can College of Physi-cians ( )and othermedical associations andorgan izations listed in Step7A:Financial Considerations. Later in this section you canfind the codes you will needto bill . (Table3: Immuniza-tion Codes Used to bill Medicareand Table4: Immu-nization Codes Used to bill Third-Party Payers.) Billing Medicare for immunizationsMedicare Part B covers the cost of influenza andpneumococcal (both PPSV23 and PCV13)vaccines,as well as hepatitis B vaccine for persons at increasedrisk of hepatitis B.

4 Medicare Part B does not coverother vaccinations unless they are directly related tothe treatmentof an injury or direct exposureto a dis-ease or condition, such as anti-rabies treatment,tetanus antitoxin, and Td/Tdap for wound manage-ment. Therefore, in the absence of injury or directexposure, preventive immunization against diseasessuch as pertussis, diphtheria, etc., is not coveredunder Medicare Part B. These vaccines and othercommercially available vaccines (such as zoster)typically are covered by Medicare Part D drug planswhen they are ACIP-recommended to prevent ill-ness. Billing for Part D vaccines goes directly to thethird-party drug coverage not reimbursed directly through the Medi -care Physician Fee Schedule, the administration of influenza, pneumococcal , and hepatitis B vac-cines (HCPCS codes G0008, G0009, and G0010) isreimbursed at the same rate as CPT code 90471for the year that corresponds to the date of serviceof the : A Step-by-Step GuideImmunization Action Coalition b.

5 How to bill for Adult ImmunizationsInnovative billing techniques, when combined with chart reminders, standing orders, and other methods of standardizing your office operations, can substantially reduce the costs of administering vaccinations in your Paul, Minnesota t 651-647-9009 t t t Item #P2050 (9/17)An unequivocal provider recommendation is One of the leading reasons adults identify for not receiving a vaccine is the lack of a recommen-dation from their provider. t An unequivocal vaccine recommendation by an Adult s healthcare provider is one of the most important interventions to improve patient acceptance of a vaccine. t Providers often don t appreciate the power of their recommendation of a vaccine, or the impact of their lack of a recommendation.

6 Most adults rely on their providers to let them know which vaccines are recommended and when they should be given. standing orders protocols 6 WDQGLQJ RUGHUV SURWRFROV DUH D VHULHV RI ZULWWHQ PHGLFDO RUGHUV DXWKRUL]LQJ D TXDOL HG L H eligible to do so under state law) healthcare professional to assess the need for and administer vaccine to all persons meeting certain criteria (such as age or underlying medical condition), eliminating the need for an individual physician s order for a patient s vaccine. t 6 WDQGLQJ RUGHUV KDYH EHHQ VKRZQ WR EH WKH PRVW FRQVLVWHQWO\ H HFWLYH PHDQV IRU LQFUHDVLQJ vaccination rates and reducing missed opportunities for vaccination. t standing orders templates for all routinely recommended Adult vaccines are available from IAC at to Improve Adult Vaccination Coveragecontinued on the next page Many vaccines are recommended for adults , but vaccines don t work unless we get them into the arms of the people who need them.

7 Despite the fact that there DUH VDIH DQG H HFWLYH YDFFLQHV GLVHDVHV WKDW FDQ EH SUHYHQWHG E\ WKHVH YDFFLQHV continue to take a huge toll among adults in the United States. Low Adult vaccination coverage rates occur for a variety of reasons, including low community demand for vaccines, lack of access to vaccination services, and system- and provider-related factors. Successful Adult vaccination delivery depends on several patient and provider factors, as well as system issues, such as vaccine supply and reimbursement. adults are unlikely to seek vaccination unless they believe that the disease is a threat to them and that there is a vaccine that can prevent the disease. They need to know that they are personally at risk. Even if they know a vaccine is available, adults also may have misconceptions about the vaccine and inordinate concerns about vaccine adverse reactions.

8 $ NQRZOHGJHDEOH SURYLGHU ZKR XVHV H HFWLYH VWUDWHJLHV OLNH WKH RQHV VXJJHVWHG EHORZ FDQ DGGUHVV WKHVH LVVXHV effective strategiesUnequivocal provider recommendationStanding orders protocolsReminder and recall systemsAssessment and feedbackExpansion of patient Medicare for additional servicesWhen administering influenza, pneumococcal ,and/or hepatitis B vaccines, you may bill for addi-tional reasonable and necessary services. Forexample, you can bill HCPCS G0008 for adminis-tering influenza vaccine and also bill for other serv-ices performed during the same visit, including anevaluation and management (E&M) service. Eachadditional service should always be justified withan appropriate diagnosis , if you use roster billing (see below),you should not list additional services on the ros-ter bill .

9 All other covered services, including officevisits, are subject to more comprehensive datarequirements; you should bill them using normalPart B claims filing procedures and billing (Influenza and pneumococcal vaccinations only)The simplified roster billing process was developedto enable Medicare beneficiaries to participate inmass pneumococcal and influenza vaccination pro-grams. (Note: Medicare has not developed rosterbilling for hepatitis B or any other vaccinations.)Roster billing also can substantially lessen the admin-istrative burden on physician practices by allowingthem to submit one claim for all of the Medicarebeneficiaries that received either pneumococcal orinfluenza vaccines on a given day. Medicare willoften refer to providers who utilize roster billing as mass immunizers.

10 For Medicare Part B submissions, physician prac-tices and other mass immunizers must submit aseparate preprinted CMS-1500 paper claim form orbill electronically for each type of vaccination (eitherinfluenza or pneumococcal ) and attach a roster billcontaining information for two or more Medicarebeneficiaries. When mass immunizers choose toconduct roster billing electronically, they are requiredto use the HIPAA-adopted ASC X12 N 837 claimstandard. Local Medicare Administrative Contractors(MACs) may offer low or no-cost software to helpproviders utilize roster billing electronically. How-ever, this software is not currently available nation-wide, so check with your local MAC for specifics in your entities that submit claims on roster bills mustaccept assignment, meaning they must agree toaccept the amount that Medicare allows as the totalpayment.