Staying Independent...Together

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   RE: vaccine billing- maybe everyone else already knows..
 From: Christopher Wenner
 To: Member Forum
 Posted: 11-01-2016 11:23
 Message:

Jean-

I don't disagree that the system is broken, but Melissa is correct in indicating that we need to 'play the game".    If we don't--we wither and get consumed by the local hospital.

Did you know that proceduralist can add a -22 modifier to a procedure indicating it was more challenging than expected, and recoup more in fees for said effort.  Do we as primary care docs have such a luxury?

Until the system is based on primary care and we are reimbursed for what we are worth we must 'play the game'.

Keep up the good work!

Chris

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Christopher Wenner
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Original Message:
Sent: 11-01-2016 10:06
From: Melissa Weakland
Subject: vaccine billing- maybe everyone else already knows..

Yes- this is only for private insurers. Medicaid has different rules because of VFC. 

Indeed- it's all a game that we have to play. The care IMPS provide is mostly outside of the game. We each have chosen to provide the highest quality care most cost effectively within systems we each create thay allow patients to access this care when they need it and its available to all patients regardless of insurance, regardless of ability for them to pay.  And the game mostly isn't about this.  but we have to play it if we want to do the above. And we keep working to try to align more of the greater game to these true goals of healthcare. But yep for now pretty darn broken. 

To me this forum is about helping to understand what the ever changing rules of the game are. And helping each of us to think about how much we want to play.  And how can we influence the rules of the game.  

PCMH- did you play this part of the game or 

ACO- part of the game some chose

Quality metric collection- another piece of the game 

MU- yep

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Melissa Weakland MD
Ballard Neighborhood Doctors
Seattle WA
IMP since 2007
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Original Message:
Sent: 10-31-2016 09:30
From: PJ Parmar
Subject: vaccine billing- maybe everyone else already knows..

yes but... my main payer, Colorado Medicaid, pays $0 for 90461.  So the additional component thing is moot, its all about how many jabs, not how  many components.  Not sure about other payers....

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PJ Parmar
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Original Message:
Sent: 10-31-2016 01:18
From: Melissa Weakland
Subject: vaccine billing- maybe everyone else already knows..

This came up in our recent regional meeting. thanks and thanks Amy.

Giving vaccines, per Amy, should help us make money.  We've always just done them to hopefully break even. And mostly because we feel we should.

I've never never coded correctly. Amy reminded us that  vaccine admin fee is charged for each component in a vaccine - and first component fee is used for ALL single vaccines.

Additional component fee is only for combination vaccines.  So a Tdap gets billed for 3 administration fees- the higher price for the first component and lower price for the second and third components.

This is a fairly large cost difference for us. 

I copied this from AAFP

"codes are reported per vaccine/toxoid component. CPT defines a component for these purposes as each antigen in a vaccine that prevents disease(s) caused by one organism. Combination vaccines are those vaccines that contain multiple vaccine components.

You may report multiple units of code 90460 for each first vaccine/toxoid component administered. No modifier should be required when reporting multiple first components. Note also that code 90460 does not apply only to combination vaccines, but also to single component vaccines (such as influenza, human papilloma virus, or pneumococcal conjugate vaccines). This base code is reported for each vaccine administration to patients 18 years of age and under who receive counseling about the vaccine from a physician or qualified health care professional at the time of administration. Code 90461 is an add-on code reported for each additional vaccine component administered.

Administration Coding Example

An 11-year old girl presents for a preventive visit (99393). In addition, the child and her mother are counseled by the physician on risks and benefits of HPV (90649), Tdap (90715) and seasonal influenza (90660) vaccines. The mother signs consent to administration of these vaccines. A nurse prepares and administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is no immediate adverse reaction.

CPT Codes reported are:
99393 - Preventive service
90649 - HPV vaccine
90460 - Administration first component (1 unit)
90715 - Tdap vaccine
90460 - Administration first component (1 unit)
90461 - 2 additional components (2 units)
90660 - Influenza vaccine, live, for intranasal use
90460 - Administration first component (1 unit)

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Melissa Weakland MD
Ballard Neighborhood Doctors
Seattle WA
IMP since 2007
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