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How Medicare handles flu shots, patient information

From the December 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: Many of my Medicare patients are requesting a flu shot. What is the Medicare benefit and how do I get reimbursed?

A: Medicare typically pays for one flu shot per beneficiary per flu season. It is important to note that Medicare does not limit coverage to one shot per 12-month period; it will pay for additional flu shots during other seasons of the year if medically necessary. It pays 100% of the Medicare-approved amount for the flu vaccination; neither the $100 per patient deductible nor the 20% co-insurance apply to flu shots.

If you accept Medicare assignment, or agree to accept the Medicare allowable as payment in full, you cannot bill the beneficiary. You instead must bill Medicare for the flu vaccine and its administration. Your payment will depend on your geographic area.

If you do not accept Medicare assignment, you can charge the beneficiary for the vaccine and its administration (the same amount you would charge a non-Medicare patient), as these services are covered under a special benefit. However, you must submit an unassigned claim to Medicare on the beneficiary's behalf.

When billing for the flu vaccine and its administration, you must fill out the data fields required for any Part B claim. Select from CPT codes 90657-90659 to identify the vaccine product. Use HCPCS code G0008, "Administration of Influenza Virus Vaccine," to report the administration of the vaccine. Use ICD-9 code V04.8, "Influenza Vaccination," if the sole purpose of the beneficiary's visit is to receive the flu vaccine.

You can bill HCPCS G0008 to report the administration of the vaccine in addition to other services performed during the same visit, including an evaluation and management (E/M) service. You should append CPT modifier-25 to an E/M service code to indicate that it is a significant, separately identifiable service. Always justify each additional service with an appropriate diagnosis code.

Although 65% of Medicare beneficiaries receive a flu shot annually, the CDC reports that the most common reason beneficiaries give for failing to get a shot is that they didn't know that the federal government recommends and pays for it. As a result, HCFA is conducting an outreach program to remind seniors of Medicare's free flu vaccination benefit. The agency is mailing nearly 8 million postcards and airing television spots in selected cities to remind beneficiaries to get immunized.

For more information on influenza and the CDC's vaccination recommendation, visit the CDC Web site at www.cdc.gov/nip. For weekly updates on influenza cases during the season, visit www.cdc.gov/ncidod/diseases/flu/weekly.htm.

Q: What information can Medicare beneficiaries get from HCFA?

A: As part of a congressionally mandated program, HCFA produces a variety of information about the benefits available under original Medicare and Medicare managed care plans.

As part of this program, HCFA publishes an annual guide for Medicare beneficiaries. Next year's handbook is called "Medicare & You 2000." Medicare's 39 million beneficiaries will receive either the handbook or a postcard that they can mail back to HCFA to request a copy.

"Medicare & You 2000" provides beneficiaries with the following information:

  • What is covered under Medicare Part A and Part B.
  • How to pay for health care costs, including purchasing Medigap insurance.
  • How to choose between original Medicare and Medicare managed care plans.
  • Beneficiary rights and protections.
  • New prostate cancer screening benefit.

Since your patients may have questions for you about the information in the handbook, you can obtain copies of "Medicare & You 2000" by faxing your request to HCFA at 410-786-1905.

"Medicare and You 2000" is also available through HCFA's Web site at: www.medicare.gov/publications.html#view. HCFA also offers the Medicare Helpline (800-633-4227) and a beneficiary Web site (www.medicare.gov).

Beneficiaries who call the Medicare Helpline can speak to customer service representatives or request written materials. HCFA reports that thousands of people are using the help line. The most common questions concern the availability of managed care plans in a particular area.

Medicare's Web site allows beneficiaries to compare the different managed care plans offered in their area. According to HCFA, this feature and the section that provides comparative information on nursing homes nationwide are the most visited parts of the Web site.

The Web site also includes updated health plan performance measures such as information on patients' overall satisfaction with the health plan; ease of getting a referral to a specialist; eye exams given after diagnosis of diabetes; and treatment of heart attacks with beta blockers.

The Web site also includes a calendar of local and national activities offered by HCFA in partnership with other organizations.

Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, call him at 202-261-4533, send a fax to 202-835-0441, or send an e-mail to bbaker@acponline.org.


FDA approves new flu drug

The FDA last month approved a new antiviral agent to treat influenza A and B, which include all common strains of the disease.

The drug, oseltamivir phosphate, is part of a new class of drugs known as neuraminidase inhibitors designed to treat uncomplicated acute illness in adults who have been symptomatic for no more than two days. Marketed by Hoffman-La Roche Inc. under the name Tamiflu, it is the first neuraminidase inhibitor to be made available as a pill.

The medicine works by targeting one of the two major surface structures of the influenza virus, the neuraminidase protein. Once the neuraminidase site is inhibited, the virus is not able to effectively replicate and spread to other cells.

Approximately 300,000 Americans are hospitalized by the flu each year, and between 10,000 and 40,000 Americans die annually from the disease.

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