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.
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)
wow I find this to be a scam PCPs use to survive egads how broken this system is I do not even use the code with counselling- I rarely need to counsel Do we actually counsel on the D and the T and the P? I do not find this to be a solution to the problem IT raises the cost of care Addtionally I doubt if the VFC program many of us use would allow Hmm we are told to use 90471 and get 28.56( whichis fine ) The private spay 30+ for that code which is also fine God things are broken
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....
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
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!
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.
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.
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.
Medicare and other insurers ('They') have the following relationship with physicians ('Us'):
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."