Avoiding Claim Denials for Incorrectly Billed Influenza Vaccines for Medicare Beneficiaries
National Government Services has seen an increase in Influenza (Flu) vaccine claims billed incorrectly by NY and CT providers. The top claim errors and tips on how to avoid them are as follows:
| Claim Denial | How to Avoid Denial |
|---|---|
| Multiple flu vaccines and administration codes submitted on one claim | Only one flu vaccine and one administration code should be submitted on a single claim. |
| Patient receiving more than one flu shot in a single flu season, not medically necessary | Medicare Part B covers 100 percent of the cost of one flu shot once every flu season with no Part B deductible or coinsurance required if you are a provider who accepts assignment. However, a beneficiary could receive the seasonal flu vaccine twice in one calendar year for two different flu seasons and Medicare would reimburse the provider for each. For example, a beneficiary could receive a seasonal flu vaccination in January 2012 for the 2011 – 2012 flu season and another seasonal flu vaccination in November 2012 for the 2012 – 2013 flu season and Medicare would pay for both vaccinations. Medicare may cover additional seasonal flu vaccinations within the same flu season if documentation shows medical necessity. |
| CPT code 90471 being used as administration code for flu or pneumococcal (PPV) vaccines | For Medicare billing, the only allowable administration code for the flu vaccine is G0008 and the only allowable administration code for PPV is G0009. CPT code 90471 is not valid for Part B Medicare flu/PPV administration billing. When providers use any other code for flu/PPV administration services, deductible and coinsurance amounts are applied to the claim incorrectly. |
| Code Q2039 submitted without documentation needed for pricing | When billing for flu vaccine code Q2039 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Not Otherwise Specified)), National Government Services requires documentation on the claim (in Item 19 or its electronic equivalent) advising of the correct/full name of the vaccine, dose administered of the vaccine and the exact and correct National Drug Code (NDC) in order to price and pay the claim. Without this information, a claim cannot be priced and processed. |
References:
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
About The Author
Anne M. Dunne, RN-BC, MBA, MSCN is Grassi & Co.’s Director of Healthcare Consulting. Anne is a Registered Nurse with an MBA and holds dual certification in nursing case management and multiple sclerosis nursing. In her role at Grassi & Co., Anne helps Grassi & Co.’s healthcare clients with various practice management issues. To contact Anne directly, via phone please call 516-336-2463 or via email at annedunne@grassicpas.com. Follow Anne on Twitter @annemdunne.
