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   RE: vaccine billing- maybe everyone else already knows..
 From: Peter Liepmann
 To: Member Forum
 Posted: 08-12-2017 01:31
 Message: Does anyone else think the Byzantine rules for getting reimbursed for vaccines, MCR well visits, etc., are just more evidence of insurers (most definitely including Medicare!) abusing us?

(From a screed I wrote a few years ago:)

Medicare and other insurers ('They') have the following relationship with physicians ('Us'):

  • They have much greater economic power
  • They use their economic power to control us
  • They create the rules for the relationship
  • We can't know all the rules (130,000 pages)
  • If we misinterpret or break the rules, they punish us by withholding payment
  • If they misinterpret or break the rules, they punish us by withholding payment
  • If they break the rules we have no recourse
  • We can't change the rules
  • They can change the rules without our consent
  • They can change the rules without our knowledge
  • They imply that not going along with their rules means we don't care about patients (quality)
  • We can't leave because they control the money, and people (patients) who depend on us would be hurt
  • They tell us we can't do anything right (frequent and routine denials of claims)
  • Their payment system (FFS) encourages overuse- exactly the behavior Medicare says they want to discourage
  • They hurt us (impose EMRs and other excessive bureaucratic tasks) then tell us it's our fault we can't comply with them
  • We learn we need to distort our behavior to survive.
  • We're burned out. That's not their problem. All we have to do is follow the rules (all 130,000 pages of them.)
  • What they pay for controls what we can do for the patient
  • They won't pay us for the services the patient needs
  • They don't trust us to do what's right for the patient
  • They don't trust us to provide the services the patient needs
  • They blame us for not providing the services the patient needs
  • They blame us when something goes wrong
  • They don't take our complaints seriously
  • They can decide after the fact that what we did was unnecessary (and thus deny payment,) when necessity couldn't be determined in advance
  • They threaten us with witch hunts (RAC attacks) where they can decide ex-post-facto that we didn't describe something well enough, and take back payment for it
  • We're guilty until proven innocent- at our expense
  • They minimize the difficulties we have conforming to their rules
  • They blame us for the problems in the system
  • They say they care about patient welfare and reducing costs, but they devalue primary care, which delivers better care at lower cost
  • Their policies have caused the shortage of primary care, but they take no responsibility for it
  • They keep saying things will get better, but they keep getting worse (more bureaucracy, decrease in primary care reimbursement after inflation, more data collection, more threats)

Now, that may not be what administrators at CMS intended, but that's what insurance companies (and Medicare) do.

What I've just described, of course, is an abusive relationship.  Many physicians understand intuitively they're abused by insurance companies & Medicare, but haven't recognized it explicitly.  Don't take my word for it.  Ask a dozen family therapists or psychiatrists whether this is an abusive relationship.  Most realize this, which is why few of them accept insurance.

Healthy relationships involve mutual respect, trust, honesty, support, fairness/equality, good communication and consideration for the other party.  Unfortunately that doesn't describe the relationship between insurances or CMS and primary care.  Abusers notoriously change their behavior after beating up their partners, buying flowers and making nice. They promise they'll never do it again. Insurers constantly trot out new programs to improve patient care and reduce cost without reducing quality. "Trust us. This time will be different."  After enough repetitions, the abused party no longer believes the abuser.

Abusers want all of the power and control in the relationship and work to maintain that situation, continuing unhealthy and harmful behavior patterns. "Couples counseling" requires both partners to take responsibility for their actions and make adjustments to their behavior.  But "couples counseling" implies both partners contribute to the abusive behavior, but the choice to create an abusive relationship lies solely with the abuser. Only if the abuser acknowledges that they have a problem with abuse and are prepared to openly deal with it can abuse therapy even have a chance to be successful. Most abusers are not prepared to admit their behavior.


Insurance companies and CMS say, "Who, me?  Just follow our rules and you'll be fine."

Peter Liepmann MD FAAFP MBA
My mission is to fix US health care
Bakersfield CA
Original Message:
Sent: 08-07-2017 22:52
From: Mamatha Agrawal
Subject: vaccine billing- maybe everyone else already knows..

Medicare Part B does not cover the tetanus shot for preventive and Medicare part D does.

90714 for Td private insurance
I use just the one admin code 90471 unless giving to vaccines but the modifer -25 has to be on the visit.

Another discovery I potentially made today is that while Medicare requires Q codes for some brands of flu shots, Fluzone seems to be 90686 with the G0008
I was wondering why I did not get paid for Fluzone many times last year while the Afluria Q code was getting paid. Previously Fluzone was Q2038. I don't feel totally confident about this.

Mamatha Agrawal, MD
Family Doctor CaryNC
Cary, NC
Live in Raleigh, NC
Solo since 2012
Practice Fusion and NueMD

Original Message:
Sent: 07-31-2017 18:33
From: Michael Safran
Subject: vaccine billing- maybe everyone else already knows..

10 years ago, most of my patients received Adacell.  I have now started to give Td booster to them.
I have questions about billing for 10 year booster:   I am answering some of my own questions but not sure I am correct.
Please comment or correct as indicated.

For Medicare:
Is it covered for routine vaccination or only for acute laceration, etc  ?
Is   90714 the correct code?
What admin code?  90471  ?
Bill 2nd Admin code for second component?  90472  ?

For HMO or private Insurance:
CPT code?  90714?
Admin - 90471  ?
2nd Admin code for 2 components?  90472 ?

Has anyone been paid for 2 admin codes?

Is Medicare covering Td at the pharmacy as part of patients Part D pharmacy plan?

Thank you.

Mike Safran

Original Message:
Sent: 11-03-2016 17:07
From: Mamatha Agrawal
Subject: vaccine billing- maybe everyone else already knows..

For years I did not charge the 90471 and 90472 for vaccines if I was charging for a visit. 

Then I took my child to the pediatrician and realized they coded a visit, the admin and vaccine (and got paid double because it's a hospital based practice!) 

I must code the visit/physical with the modifier -25 in order to get the admin fee plus visit plus vaccine. 

G0008 for Medicare flu admin

G0009 for Medicare pneumovax admin. 

Other unrelated thing --- Medicare is do a visit with modifier -25 + the G0439 Medicare annual wellness together. It's the rare Medicare patient who only comes in for the bare bones annual wellness questions. 

Mamatha Agrawal, MD
Family Doctor CaryNC
Cary, NC
Live in Raleigh, NC
Solo since 2012
Practice Fusion and NueMD

Original Message:
Sent: 11-02-2016 10:50
From: Kathy Saradarian
Subject: vaccine billing- maybe everyone else already knows..


I'll have to check EOB.  That sounds like an error to me.  Never heard so much for administration.

Also, that bill per component thing is only pediatric vaccines, not adults.  The counseling code is only pediatrics.  I guess adults don't need counseling.  

Kathy Saradarian

Original Message:
Sent: 11-01-2016 23:07
From: Amy Adkins-Dwivedi
Subject: vaccine billing- maybe everyone else already knows..

The vaccine billing at least in our neck of the woods seems to definately take up quite a bit of time.  Between the people that do not want to vaccinate, try to do something that isn't even possible such as get rubeola by itself.  It is time consuming.  

The caveat is that it is only for children, for adults with the 90460 and the 90461.  It really does help us pay overhead with the reimbursement.  

Medicaid is totally different, we get reimbursed somewhere from 5.60 to 23.44 for the vaccine, but not for the administration.

I know adults have a seperate code for vaccine administration, which looks quite high.  I just reviewed my own eob from a practice where I got my flu vaccine.  Insurance paid 19.11 for the vaccine and 54.00 for the administration.  That in my books is huge.  that is way more than we get paid in my clinic for a vaccine for the 90460, even with extra components.

Amy Adkins-Dwivedi
Stepping Stone Pediatrics

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)

Melissa Weakland MD
Ballard Neighborhood Doctors
Seattle WA
IMP since 2007

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