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    Billing for a flu vaccine with an annual visit


    Renee Stantz
    Q: When patients with traditional Medicare come to our office for an annual wellness visit (AWV), we also administer flu shots. If we bill G0438 with the 25 modifier along with flu shot codes, Medicare denies the claim. If we don't bill the modifier, Medicare pays only for the flu shot and not for the wellness check. What do we do in this case? Asking patients to come another day would be an inconvenience for them.

    A: Since May 1, 1993, Medicare has paid for flu vaccines and their administration. Generally, only one flu vaccination is medically necessary per influenza season. Medicare beneficiaries may receive the vaccine once each flu season, paid by Medicare, without a physician's order and without the supervision of a physician. State laws regarding who can administer vaccines still apply. Flu vaccines are covered under Medicare Part B, not Part D, and the Medicare Part B deductible and coinsurance do not apply. Additional vaccinations may be covered if medically necessary.

    The AWV code—G0438 or G0439—is payable when billed on the same date of service (DOS) as the flu shot (see the chart on this page) and administration (G0008) without appending the 25 modifier to the AWV code. If an evaluation/management (E/M) code is billed in addition to the AWV, the 25 modifier should be appended to the E/M code to denote a significant, separately identifiable service.

    If you get a denial when these codes are billed on the same DOS, check the denial reason code. There might be another reason the AWV is being denied. If the patient did not become Medicare-eligible in the past 12 months, he or she is eligible for the initial preventive physical examination (IPPE) instead of the AWV. Also, make sure that the patient has not had an AWV or IPPE from another provider. G0438 is a once-in-a-lifetime benefit, and G0439 is payable once every 12 months for each beneficiary.

    Medicare's denial reasons for these services are very specific, so you can gain a great deal of information from them. If you are unclear as to what the denial means, contact your local Medicare carrier or see Medicare's Remit Easy Print Users Guide, which is available on the Centers for Medicare and Medicaid Services (CMS) Web site here https://www.cms.gov/AccesstoDataApplication/Downloads/EasyPrintUserGuide.pdf .

    Because Medicare has not identified specific diagnosis codes to substantiate the AWV, the diagnosis code should not be the basis for denial. If you are in doubt, contact your local Medicare carrier for guidance.

    The chart on this page shows the flu vaccine Current Procedural Terminology (CPT) codes that can be billed. Don't forget to bill the flu administration code (G0008) in addition to the vaccine. One of the diagnosis codes shown in the chart should be billed and linked appropriately on the CMS-1500 claim.

    To learn more about flu and pneumonia vaccines, see the 2011-2012 Immunizers' Question & Answer Guide to Medicare Part B & Medicaid Coverage of Seasonal Influenza and Pneumococcal Vaccinations on the CMS Web site.


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