Billing Flu Shots to Medicare and Commercial Insurance Companies
Since it is now flu season I have been getting a lot of questions on how to bill flu shots to commercial insurance companies and Medicare. The codes used for a particular vaccine will vary depending on intramuscular vs. intranasal use, age of the patient, formulation, preservative-free, and split or live virus. If you are unsure of what code to use I suggest looking at the package information
that came with the vaccine. Usually, you can find the code on the packaging, and if you can’t find it in the documentation then call the supplier.
This is how most of our primary care practices bill for flu shots. Your situation may be different so make sure to check all the influenza vaccine codes 90654-90668 and use the appropriate code for the vaccine administered to the patient.
Commercial Insurance Carriers
- 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
- 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
- G0008 Administration of Influenza Virus Vaccine
- Q203x Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Keep in mind that there are several codes for the flu vaccine when you bill for Medicare flu shots. The code you use is dependent on the manufacturer of the vaccine. Replace the code above with the correct vaccine code below.
Here is the list of the Medicare Flu Vaccine codes. Choose the code based on the manufacture:
- Q2034 Agriflu Vaccine: Influenza virus vaccine, split virus, for intramuscular use (Agriflu)
- Q2035 Afluria Vaccine: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
- Q2036 Flulaval Vaccine: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
- Q2037 Fluvirin Vaccine: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
- Q2038 Fluzone Vaccine: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
- Q2039 NOS (Not Otherwise Specified) Vaccine: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)
Check out the short video we made about coding for the Medicare flu shot CLICK HERE
If a child is under the age of 9 and has not previously received a flu shot, then usually two shots are given one month apart. After the initial series, in subsequent years only one shot is needed. When billing for the initial flu shot keep in mind that insurance should pay for both the initial flu shot and the flu shot given 30 days later. Be sure to follow up with the insurance companies if reimbursement is not issued for the second shot of the initial series. Typically these are denied but can be paid with a simple appeal or phone call correcting the denial.
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
Use the age-appropriate codes as needed:
- 90657 Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use
- 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
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Do you know the new CPT codes for billing the Coronavirus Vaccine and administration fees? Check out my CPT Codes for Coronavirus Vaccine post.
125 thoughts on “How to Bill Flu Shots”
Our clinic in the past has provided flu shots FOC to all employees. We are considering billing the companies’ commercial insurance for the flu shot. Can we do this?
Hi, How do I bill a commercial wellness visit , plus and E & M , plus a flu vaccine with administration with appropriate modifiers. I put 25 modifier with the E & M and 59 with the flu administration and it was denied by UHC PPO plan , Thanks so much
Hello, I realize this is an older article but perhaps you still receive comments.
I work for a SNF and we provide flu shots to our employees. Are we able to bill insurances for the vaccine and administration? And how would we do that since we are not setup to bill anything outside of our residents.
commercial insurance is denying 90471-59 for flu shot? How should it be billed with a 99213-25 office visit
I WORK FOR A FQHC AND WE BILLED 99213 – 25 WITH FLU AND 90471. THE 99213 AND 90471 GOT BUNDLED TOGETHER. IS THERE A WAY TO GET THE 90471 PAID SEPERATELY? IT WAS FOR OVER 3 YEARS OF AGE.
Hi, New here to site and love it.
I am billing a CPE 99385 and need to bill a flu vac 90674 and G0008 but my system sweep tells me it will be denied. Do I use a modifier on my CPE code ? Thanks so much for your help.
We billed procedure code 90674 with 90471 modifiers listed as 59, SY but still denied. What other modifiers are valid for these procedures? I appreciate your response.
Unless the insurance company requires a specific modifier we usually do not need to include one for flu vaccine claims to get paid. What was the specific denial reason on the EOB?
We are pcp provider and keep getting denial for administration code 90471 from united healthcare community plan and amerigroup. We know for vfc they paid fo serum code only but we also get denial for adult also – Really appreciate your help and time please – Thanks
Each state can have different requirements. In general with Vaccines for Children (VFC) you get an administration fee that is either paid on the admin code or on the vaccine code. I would check with the carrier on exactly how they want this billed.
If you have a patient with a commercial insurance policy as primary and medicare part b as secondary; which administrative code would you bill? 90471 or G0008?
Kasey, I would bill 90471 to the commercial and then for Medicare secondary use G0008.
how do you bill for older than 18 flu vax with a physical or follow a follow-up exam
During a flu clinic performed by a nurse, if billing under the provider, is it required that the MD sign every note?
I ran pediatrics flu shot clinics where hundreds of kids showed up. We did have the doctor sign the order.
During a pediatric flu clinic, Can you bill under a physician if he/she is not present in the office at the time of the clinic?
Hi I work for a Hospice in NC and we are wanting to provide flu shots to our patients who request them. How do we bill for them? Also, if a nurse practitioner provides the shot, may we bill under the nurse practitioner or only under the attending doctor? Thank You!
We are a Pediatric Group. Is there a way to bill for the vaccines we gave to our Central Business Office employees without having a physician sign off. Do they need to be billed under a doctor or can it be billed as Nurse only?
For example, what happens at Publix or CVS when no doctor is present?
How would you bill for half of a flu shot? (90688) Patient received half the shot and will be coming back in 4 weeks for the other half.
Nice information! Thanks for providing valuable information.
Glad you enjoyed the post!
Can we use Q2038 for 90688 for Medicare insurance. Please suggest.
Hi Atul –
I would take a look at the package insert or any material that the influenza vaccine manufacture provided to you to help in choosing the correct code. The two codes you mentioned are for different vaccines.
Here is a link to “Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B” MLN that may help.
I would recommend that you provide an updated article since this one references information and codes for 2011.There are new codes and new recommendations.
Hi Diane —
I did do a followup post but since lots of people are hitting this page it does make perfect sense to update the info. DONE!
Anyone have experience in billing flu shot for MN Medicaid. I know the DX code is Z23 but which CPT and modifier do you use. I submitted a couple and always denied.
Par look at the following codes:
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
That said, MN Medicaid may have their own set of requirements to bill. Best to contact them or go to their website. Medicaid may have the policies to bill the flu vaccine properly according to their guidelines on the site.
I own a mobile phlebotomy and health service company and want to start giving flu shots and vaccines. How do I bill and accept insurance? I live in California.
Andrea first you will have to get credentialed with each insurance company if you can. Give one a call to get the process started. It can take 2-6 months. Once you are credentialed and have a contract with the insurance company you can submit claims as an in-network provider. You can still bill insurance if you don’t have a contract but will be considered out-of-network and insurance may not pay or pay the patient directly or have higher out of pockets for the patient.
I have billed out office visits (pt in for a sick visits peds) 99213 and when flu shot was given, we used mod-25, SL and admin fee 90460 on our AZ AHCCCS (medicaid) patients, but the office visit gets denied. When i called ins comp they just repeat the same line that it wasn’t coded properly but they can’t help me with what the proper coding is and refer me to their web site which id no help.
I don’t know if the attached will help you. It states both the admin and serum need SL modifier.
Thank you for the information! I am researching how to code for 1/2 doses of flu in children and elderly and they come back 28 days later for the other 1/2.
My thought process is we will bill for the flu vaccine on inital DOS, but not the follow up. If we don’t have a vaccine to bill out on the second DOS, we would also not have an admin fee.
Any help would be greatly appreciated.
We do send claims for Maryland state, I am encountering the following problems with all Medicaid groups – eg- uhc mid atlantic, Maryland physicians care, amerigroup,americaid, etc…
while we bill 99213 – 25 – 401.1 and 90658 -v04.81 and 90471- V04.81 , always administration code is denied stating STATUTORILY EXCLUDED SERVICE, but who is going to pay our administration services.
Its been a long time issue, need help Manny
Sue each state’s Medicaid program is different. Unfortunate we don’t have any clients that bill Medicaid flu shots in Maryland so I may not be much help to you. I would not be surprised that Medicaid HMOs don’t cover the admin code. Is it possible that there is another code they would like you to use instead? Maybe becasue you have an office visit they are excluding the admin.
I would contact your rep and check on the Medicaid and HMOs websites for their guidelines on billing flu shots. Also I would not use a 25 modifier on the visit. It is not necessary in this case unless it is a carrier specific rule. You are using ICD-10 codes? Z23 Encounter for immunization.
Oh boy, I have not billed my medicare flu billings yet, however they have been getting paid with my billing to third party insurance companies, and I use the G0008 & Q2035 $15.00 for each code and I use the diagnosis code Z23. I am at a loss on that one, if insurance pays out why won’t medicare???? Sorry no help at this point, I will let you know how mine pay or don’t pay when I bill them. I plan to use the same codes as you mentioned. urrrrrr………..
It would be great if you could keep me up to date on how you make out. Thanks a bunch!
Hi, can anyone please tell me what is the difference between codes 90686 & Q0238. To me both has the same description.
90686 is a quadrivalent and Q2038 is a trivalent.
You will find supporting documentation at this link. I hope this helps.
We are billing flu injections to Medicare with a G0008 administration code and the appropriate vaccine code with a diagnosis code of V04.81 for ICd-9 (Before October 1st) and Z23 for ICd-10 (after October 1st) and the G0008 code is being denied. We have called Medicare and they tell us that they do not cover the administration (G0008) with the diagnosis codes were are using because it is routine? Everything we look at says to use one of these two diagnosis codes for the admin and vaccine. Does anyone have any idea why they aren’t paying? What other diagnosis code could we possibly use?
The word “Byzantine” does not seem to cover it.
Hello. Would you be so kind as to tell me which modifiers I use for codes Q2037 if any and for 90732 for Medicare for 2015??? Trying to find out without having to call the boss. I haven’t used these codes since last year and don’t know what to do. Thank you so much for your help, I appreciate. Barbara Wright
we use Q2037 for the medication and G0008 for administration for both medicare and commercial.
Hi, if a patient with commercial insurance is having Fluvirin flu vaccine, what code can we use? 90658 is being denied.
Hi Manny! I work for a Public Health Department and we will be billing Medicare for flu shots. I have a few questions. If we charge $30 for a regular dose flu vaccine (codes Q2035 – Q2038), can the total we bill Medicare for the vaccine + admin code (G0008) be more than $30? Would we bill Medicare the same total regardless of which type of regular dose flu vaccine we give (Fluvirin (Q2037), Fluzone (Q2038))? My understanding is that you cannot bill Medicare more than what you charge, but someone is questioning that. Thank you very much, your blogs are very helpful!
If you are charging $30 for the flu shot only, then I would say that the max you could bill Medicare is $30.
Charging Medicare $30 for just the flu shot is reasonable. They will just have you write-off anything over the allowable.
Where I see an issue is that you are not charging the self-pays an admin fee but you want to charge Medicare the admin fee on top of the vaccine. So now you would like to charge Medicare, say $40 total as an example ($30 vaccine + $10 admin). I don’t think I would do that.
Moving forward I would consider dropping the price of the flu shot and charge self-pays $20 for the vaccine but then charge $10 for the admin fee for a total of $30. Or something like that.
Now I would be comfortable billing Medicare the same way.
To make sure I am understanding, if our $30 charge for self-pays includes the vaccine & admin fee, we should bill Medicare the same way? And we would bill the same for each of the Q codes, since that is what we charge self-pays?
That’s what I would do.
My son received a flu shot at his pediatrician 11/4/2014 and the insurance was billed a 99211, 90471 and 90686. However he only saw the nurse who obtained his vitals, and then gave him the flu shot. Now they are saying I have a copay for the 99211. I was always under the understanding you can not bill and office visit and an administration code. Is this true? If so, where can I direct them to look this up to prove this to them? Because my insurance covers the flu vaccine 100%. But state the dr office would need to re-submit the claim without the office visit which they are refusing to do. The dr office claims they can charge for both because the nurse has to determine if the child is well enough to receive the shot.
I am very surprised that the insurance actually accepted the 99211. In days past that was the way to bill for flu shots but nowadays most insurance companies only accept the 90471 and not both codes together.
My guess is that the practice put a different diagnosis on the 99211 that was unrelated to the flu shot to allow it to be processed by the insurance company, but that is only a guess. Without knowing the exact codes and insurance company billing policy for flu shots there is no way to know if this was appropriate with just the information you provided.
If you want to pursue this I would call the insurance company to try to get their flu shot billing polices and get a copy of the chart notes from your doctor for the shot along with the the CPT and ICD-9 codes that were billed to insurance.
With that information you may be able to work with your insurance company to get this resolved one way or another if the practice is not willing to help.
Note that even with doing all this work the outcome may still be that you owe the copay.
Yeah I am just going to end up paying it. I’ve spoke with my insurance company and they rejected the 99211 because there wasn’t any other diagnosis codes with it and they paid on the flu and the administration charges. The dr office states they can justify the 99211 bc the nurse has to assess to make sure the patient is healthy for the flu shot. However I even sent them documentation regarding the administration charge showing them the vitals and assessment are all covered under the administration charge. This was from the American academy of pediatrics. Even giving examples on how a 99211 could be justified but they still want to say they can bill for both just because the nurse took his vitals to make sure he was healthy enough for the shot. It’s very frustrating and seems like double billing to me. But I’m at a loss and am still stuck paying it. I can tell you what, I will not get another flu shot there when I can take my son to my work or a pharmacy and get it with no cost since the insurance covers it.
Based on your comments it sounds like they don’t know how to bill flu shots. Sorry.
Does a Medicare vaccination claim require a rendeing NPI? E.g. If a Medicare patient is provided a flu vaccination when there is no provider in the physician office(there is just a nurse), should I still bill it under the physician’s NPI as rendering? If not, what should I do? Is there a Medicare reference to cover this situation?
Do you know if the flu shot covered from commercial insurance (including BCBS Medicare Advantage)?
Yes usually flu shots are covered by commercial carriers and Medicare.
Is the flu shot covered by Blue Cross Blue Shield with the procedure code 90658?
Also, are administrative fees with the code G0008 covered by Blue Cross Blue Shield? I used these codes to bill, but they are saying it is PR-27 which means it’s the patients’ responsibility.
Syed the flu shot should be coved by BCBS. Also don’t use G0008 for commercial insurance. The G code is for Medicare only. Use 90471 for the admin code. You may have to give Blue Cross a call to find our what gives as they should have paid.
I have a question. One of our providers are going to a health fair and is administering flu shots. When we go to bill the flu shots we are billing with the POS 60. what address should we be using? The actual physical address of the health fair or our physican office address?
Many NYC insurances are rejecting 90661 (Novartis flu Vaccine).
any idea why?
Well 90661 is a newer vaccine. The FDA approved it only 2 years ago. Medicare started covering the vaccine only last year. Of all our clients we do not have anyone that uses that vaccine.
Sometimes it takes a while for the insurance companies to catch up. I have seen that in the past. I would think by now though all those issues would have been resolved. It’s been a while.
Unfortunately you will have to appeal each rejections. I would also call your rep to see what is going on. The only other things to look at is to check the correct NDC number is being used when submitting the claim and the DX is V04.81.
I work for a hospital and we’ve recently given our nursing home residents their annual flu shots. I have a patient that received the flu shot after he was discharged from an inpatient stay and I’ve been told that I can bill that separately – is there a specific condition code, etc to use in this case? Also, some of the patients have other outpatient accounts on the same date of their flu shot (lab,xray)
Our clinic has been asked to come to a factory to give flu vaccines to their employees. We are in Mississippi. Our providers want to bill the workers’ insurance. Can we do this legally if we are giving them in the workplace? We just want to be sure we don’t do anything wrong.
It would be easier to just collect a cash payment from the employees or better yet if the factory would pay you for the flu shots becasue they would benefit much more than the costs of the shots by employees not calling out sick.
But since you want to bill the employee’s insurance I don’t see an issue with that. I would make sure to use the correct place of service when you bill the admin code and the vaccine, POS 60.
That said since you are dealing with the same insurance company for all the employees I would call the insurance and specifically ask them how to bill for the flu shots. That way there is no question that is is being done correctly to get you paid fast.
Thank you. They have BCBS so I will call them and make sure there is no problem.
Sound like a plan to me! You don’t get paid much for the flu shots so you want to make sure they fly right through and you don’t have to do any follow-up. Contacting BCBS is what I would do. Hope it all goes well for you!
Is it correct to charge a “nurse visit” 99211 when administering the Flu vaccine?
No, gone are the days when insurance companies would pay for a “nurse visit” and an administration charge along with the vaccine.
You can only bill for the admin and vaccine. Insurance will reject the 99211. –Manny
I work for an allergy and respiratory clinic in IL, but a few of our doctors are primary care physicians as well. They believe with the lung issues our patients have a second flu shot in a flu season is medically necessary, but we are not getting payment from medicare. I have appealed each patients flu vaccines twice and still no luck. I didn’t know if there is a trick or some certain information they are looking for to help get these paid. Thanks for your time!
According to the CMS website “Medicare may provide additional flu shots if medically necessary” see this link:
What are the denial reasons for the appeals?
You might also want to look at HCPCS modifier –SC Medically Necessary Service or Supply to see if that allows for the additional benefit.
Did you try submitting the second flu shot with the -76 modifier for repeat procedure?
Even when you submit the medical documentation and an appeal letter what is their specific response?
Please be sure to check with your local Medicare Administrative Carrier. They should have information on their requirements to bill this properly.
We have sent in notes along with medical necessity letters but they state in the denil letter from the appeal that it is not covered by medicare. The information recieved does not support the need for the services. That is really all the further they go as to why it is denied.
We have not tried either of those modifiers on these flu vaccines. Would we attach a modifier on the flu vaccine, administration, or both?
I will also try our Administrative Carrier to see if they have any ways to help me.
I work for a specialty practice of Nephrology. How do you bill NC Medicaid for patients who are seen for an office visit, usually a 99214, and then also obtains a flu shot while they are here. We have billed the 99214 with modifier 25 attached to the E/M code with different diagnosis from the vaccine for influenza. We use Q2036 for Flu-zone and also 90471 for administration but Medicaid paid the office E/M code but no reimbursement for the vaccine or administration. Can you help please? Thanks
We are trying to bill Tricare for the Nasal Flu Mist – we are unsure of the units of measure?
Manny – Thank you so much for all the info you provide, it’s extremely helpful! I work for a public health/home health agency and am trying to bill Medicare for the flu shots provided this past fall. What Q code do I use for the Fluzone High-Dose(IIV3)? All the information I find lists it with the CPT code of 90662 but I do not find a Q-code for Medicare. Q2033 is the only code that has a payment allowance high enough to cover our cost. Do I use the Q2039 with our cost plus the administration G0008?
Diane Medicare does not have a Q code for the high does influenza vaccine. I would use 90662 with a G0008.
Hello Mr. Manny,
I find your blogs very informative and helpful. I have started to follow your page in facebook.
I am from a home care and we provided flu vaccines in some senior communities. I billed medicare using G0008 and Q2038. I will be billing Private Insurance like Aetna, Humana, HAP, Priority Health and BCBS Freedom Blue. Should I use the same codes or it should be different? Also we are using UB-04 forms to bill these private insurances. Should there be treatment authorization codes (line 63 of UB-04) and Value Codes (line 39 of UB-04) or i can just leave that one blank? Thank you very much and hoping to hear from you very soon.
Thanks for the Facebook LIKE! The codes you are using are correct for Medicare or Medicare Advantage programs. For patients without Medicare I would use 90471 and the appropriate flu vaccine code such as 90658. Some of our practice do home care but all our billing is done on CMS-1500 so I can’t help you much with your form.
Thank you very much for the response. I will try those codes. Your blogs are really helpful for those in health industry. I plan to view more of your blogs as I have find it really informational. Thanks again and more power to you and Capture Billing.
Thanks for the nice words. If you have a minute would you please consider going to Google and write a review for me there there? Here is the link https://plus.google.com/+CaptureBilling/posts Just click on the pencil icon when you get there. Thank you!
Thank you so much for doing this. I work for a pediatrics office in GA and I am having trouble getting Medicaid to pay for vaccines and some Well Baby Care visits. Did something change as to how we should submit these claims? I enter them electronically. I add the EP modifier. Sometimes they pay them but most times they don’t.
Mallory do you participate in the Vaccine For Children (VFC) program in your state where the vaccine is provided by Medicaid? That is the only reason I can think of that your vaccines are not getting paid without seeing the EOB denial codes.
Manny , love your blog. It is very informative!
Mallory, did you ever figure out what the problem was?
My practice is in GA as well and we are having a problem with Medicaid/VFC paying for the vaccine admin (90460) fee. We are billing the Vaccine CPT along with the 90460. We use EP modifer and 99 POS. Can you tell me what we are doing wrong? Thanks in advance!
Asia each state can have their own requirements for billing Medicaid. As I understand it, Georgia Medicaid wants you to bill a VFC with the vaccine CPT code, 90460/90461, an EP modifier and a POS 99 (Other Place of Service). Is that correct?
Some states like 90471/90472 for the admin of vaccine and I have not come across any plan that wants a POS of 99. Usually its the office POS 11.
Also some plans pay on the admin code while others pay on the vaccine code. Whichever code Medicaid pays on they only pay the $14-$28 for administering the vaccine since the vaccine is provided by the state.
The only thing I can say is to call your Medicaid rep (which I know may not be the easiest thing to do) or look on the GA Medicaid website. We have usually have found how to bill services and procedure on the websites.
We have a local employer wanting us to immunize employees for influenza and they want the pharmacy to bill their medical insurance thru the wellness program. We contacted Anthem and inquired about this and was told only physicians can bill medical insurance. The Influenza vaccine is not covered by the employee’s prescription drug card. So, how do you go about billing someone’s wellness program / medical insurance?
Tim — The two ways I have heard it being done is 1) there is a physician associated with program that is credentialed with insurance companies such as a private practice doctor who goes to a workplace and provides the flu shots or 2) the employer pays for it. CASH is the way to go!
Please tell me how a MD that goes to the job site and gives flu shots actually bills the insurance. I know there is a way – location, site?? is it 15 , 18 o 11 or 99? Then do we bill everything else the same. We are contracted with commercial health insurance (no medicare or medicaid). We provide flu vaccine at the job site – employees health coverage includes a flu vaccine. Problem is industrial workers work 7 days a week shift work. Doctor appointments mean time off the clock.
Please give example of location code and correct billing practice for this type of service. CASH is best but the employer knows they already pay for a flu shot thru the preventative program so they asked that we come to the job site.
I know you are talking about commercial insurance but take a look at this article from CMS about location code 18:
Also, in a presentation from our local MAC (Novitas) from March 19, 2014 there is additional reference to place of service Code 18:
Unless you have an actual mobile unit then I would not suggest using the POS for mobile unit.
Since you are traveling to job sites where the employees will all have the employer-provided health insurance be sure to check directly with that payer. They should have the info on how they want it billed. Hope this helps.
We are a medical clinic that has homebound patients on hospice. The hospice service does not supply flu shots. The hospice nurse would like to pick up a flu shot from our clinic and go give it to the patient.
I’m fine with this but can we still bill medicare for the flu shot even though it was given in the patient’s home by a nurse who is a hospice nurse and not an employee of our medical clinic?
If so then how is it coded?
Good question Tim. The issue here is that the nurse does not work for you. It would be no problem to bill if the nurse was in your employ. When dealing with Medicare you want to be sure you do it right.
If there were only a 2 or 3 patients I would think about just not even charging for it but with that the other thought I would have is about malpractice coverage.
What if for some reason the patient has a bad reaction to the shot. The family blames your practice because you provided the vaccine. But wait, you did not provide the service, does that mean that your malpractice carrier will not cover you? Well you always have your general liability insurance coverage. But wait again, they may not cover you because this has to do with a medical issue.
I am not a lawyer or even play one on TV but we had a similar situation come up and decided not to even provide the vaccine on the remote chance something would go wrong because after talking to our carriers there would be no coverage.
I would encourage you to talk to your insurance companies and attorney before going forward. And yes it is a shame we have to do that.
I have a question about doing an off site flu clinic. We have a local college that would like us to come to an open house that they are having and offer flu shots to the students with and without insurance. My question is, would the billing be any different for giving the shot outside of the clinic? We bill place of service 11. Would we have to use a different place of service?
Bridgot the Place of Service (POS) code is 03 and is defined as, School, a facility whose primary purpose is education. You can find all the POS codes in the front of your CPT coding book. Full Disclosure: I have never billed flu shots given at a school but that is how I would bill it.
How do you bill a flu shot under Wellness for Blue Cross? Patient did not see the doctor only got a Flu shot. We have not had flu shots in years and I have forgotten “Wellness” rules.
Melissa, unless your Blue Cross has some special rules in which case I would check with them, for commercial insurance I would bill 90471, Admin of Vaccine, with the appropriate flu vaccine code such as 90658, with a DX of V04.81 on both CPT codes. Don’t use a well check diagnosis like V70.0 or V20.2 as may say that they had a full well check based on the DX. You know how those insurance companies are.
I work for a hospital. Can you get reimbursed for giving vaccines to employees and their family members? We administer free of charge to all employees and their family members who reside within the home. I was always told you cannot bill for flu vaccines to employees in a hospital.
Diann what I have heard is that if you require a flu shot as a condition of employment you should not bill that to insurance. That is basically what is happening at hospitals and large medical practices. It would be a cost of doing business. Family members may be a different story since they are not employees. As a management decision the facility may just decide to cover the cost of each family member.
I have a simple question. Who can bill for the flu vaccines? We have RN’s in the office that would like for us to submit the flu vaccine to patients insurance?
Samra we have many practices where the nurses give the flu shots to patients under the doctor’s order and supervision. The flu shot is then billed under the physician.
Have been pleased to see your good advice so far.
We have been billing flu shots this year with and without a separate visit, generally 99213 or 99214. We bill through Palmetto GBA, who is notorious for errors.
On a recent page of EOBs, we were paid for several and not paid for 4 submissions. In each case the remark code was M25 on the Q2036. We billed G0008, 90656 and Q2036 for all. The G0008 was always paid, the 90656 was never paid and the Q2036 was paid 2 of 6 times. In each case, we used V04.81.
One suggestion was to use modifier 25, though we have not needed this in past years and the paid claims this year did not have it. Can you understand this and advise?
First lets see what Medicare Remark Code M25 states:
Well that denial description is as clear as mud.
I am going to make the assumption that when you are billing a level 3 or 4 E/M code for problems the provider is addressing with the patient, you are not including the V04.81 diagnosis code with the office visit CPT code. If you have that could be causing problems.
Modifier 25 does not apply in this case.
Now lets look at the flu codes you billed:
G0008 Administration of Influenza Virus Vaccine
90656 Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
Q2036 Flulaval Vaccine: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Are you saying that you billed both a 90656 and a Q2036 on the claim for the same patient? If so you are billing two flu shots.
Let me know if this helps or you have additional questions. Also check with Medicare as they have lots of good information on billing the influenza vaccine on their website.
I just happened upon your website and I must say that the information that you provide is great. The coding profession needs more selfless individuals like yourself. I subscribed to your YouTube account and look forward to following you. You are a great man and what you provide is invaluable. On behalf of all of the coders and medical professionals that you have helped I would like to “Thank You!”
Jodi thank you very much for your kind words. I wish I had more time make videos, write blog posts and teach. Several on my teammates also have a passion to help coders and billers and do so by teaching medical billing and coding to people at our local community college and at events around our area. Thanks again. –Manny
Manny , I heard that you can bill the flu quesitionaire(4 quesitons) that patients have to complete prior to getting the vaccine. Is that true and if so what is the code?
Michele, that is covered under the administration of vaccine code 90471. That admin code plus the appropriate flu code is all you can bill. Long are the days when you could also bill and get paid for 99211.
Can you charge say $18 for a cash price for a flu shot and if billing to insurance say $32?
Good luck getting $32 from an insurance company for a flu shot. I don’t know if I have seen a reimbursement that high in recent years. Some practices do offer a time of service payment discount which sound like what you would like to do. Check your insurance contract to see exactly what you can and cannot do.
We started administrating vaccines for children [Hep A 90633, Diphtheria Tetanus Toxoids 90700, Rotavirus 90680, MMR 90707, etc. As I read about the admin codes to use, they become confusing and sometimes I feel there is information missing or out of sequence – i.e., if I bill for the CHCUP 99382 with the Hep A and the MMR, maybe the Rotavirus, can you address me where to read how to bill or give me an example. Thank you very much!
Well Lal there are a couple of ways you can bill your well child visit with immunizations.
You can bill using the vaccine admin codes 90471 and 90472 as follows:
You can also bill using 90460 and 90461 as follows:
So what is the difference? This is what CPT says . . .
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)
Use the administration codes that best describe what you are doing at your practice. Make sure you document well.
We usually use a diagnosis code of V20.2, Routine infant or child health check, which includes developmental testing of an infant or child, age appropriate immunizations, routine vision and hearing testing. That ICD-9 code would go with all the CPT codes.
It would also be appropriate to use the individual vaccine ICD-9 codes with the vaccines instead of V20.2. The claim for the vaccines would look like this:
90633 V05.3 Need for other prophylactic vaccination and inoculation against single diseases, viral hepatitis
90707 V06.4 Need for prophylactic vaccination and inoculation against combinations of diseases, measles-mumps-rubella [MMR]
90680 V05.8 Need for other prophylactic vaccination and inoculation against single diseases, other specified disease
Check with your insurance carriers on how they would like these visits billed. Each may want something a bit different.
Let me know if this was helpful or if you have more questions. –Manny
I have just started an online Medical Coding and Billing course. I am very excited to begin my new career. If you have any advice for a newbie it would be appreciated! I found you on twitter and enjoy reading you comments. All my books teach the ICD – 10 Codes. Thank you!
Susan good people are always going to be needed in medical billing and coding. With all the new rules and changes the government and insurance companies will be implementing over the next few years and the transition to ICD-10, I believe there will be job security in our field. The key is to make sure you keep studying and gaining experience. We have several team members here at Capture Billing that have 10-20+ years of medical billing and coding experience and hardly a day goes by where we all don’t learn something new because of the ever changing world of healthcare. Our people read a lot, get ongoing training and have access to great resources in order to do their jobs properly. You really must have a good attention to detail to succeed.
Now taking classes is a great start, but only a start. It will take you another good year or so in a medical billing position, getting hands on experience, to really be able to understand all the concepts. The learning will then continue throughout your career. Remember, Attention to Detail.
Best wishes to you –Manny
What is the right CPT code for flu shot for medicaid patients?
Usually you can bill Medicaid as you would commercial insurance. That said, each state can have their own rules on how they want the flu vaccine billed. Additonally, most states have a Vaccines For Children (VFC) program that provides the influenza vaccine at no cost to the patient. You will have to check with your states Medicaid. You should be able to find the billing information on their website.
Hope this helps –Manny
I work for a hospital and was told that we can bill a level 1 or 2 for just a flu vaccine. Is that correct? Seems a little unreasonable for just a flu vaccine without having anything else.
Rudy, I want to understand clearly, are you saying that if a patient comes into your hospital just for a flu shot and no other service is performed the hospital administration is telling you to bill up to a level 2 visit along with the flu shot? How do you know if its a level 1 or level 2? Are you looking at the chart notes? Level 1 can be for a nurse and level 2 for a physician, NP or PA. Sounds like you are just suppose to pick one regardless?
That said, if the only service you are providing is giving a flu shot, at best you can only bill a level 1 but even that is not billed any more these days. The administration of vaccine code 90471 or G0008 for Medicare is about all you can bill allong with the influenza vaccine codes.
Is there anything else to this story? Are they telling you why? What diagnosis are you using for the E/M visit? Is it different?
I know I am asking more questions but this seams very odd and interesting. –Manny
Quick question about the flu shots. Do you know if Medicare and the commercial insurance companies are requiring the NDC on all claims? I have been trying to research it but I am not able to find anything. I know you said Tricare does require it but I was wondering about everyone else. Thanks for your help!!!!
Yes Tricare does require NDC numbers. I am not sure if Medicare or commercial insurance companies require the NDC. I never looked into it. The reason it does not matter is since we had to include the NDC for Tricare in our computer system the NDC is now automatically picked up and sent with the other vaccine data to all the carriers.
Polly I am not sure if I am answering your question but once you include the NDC in the code tables of your practice management system everyone gets it. –Manny
I am looking for some tips on billing for a Pediatric office. For comm'l carrier and of course BCBS Healthchoice/Medicaid. well child visits and etc.
Sheila we bill for a bunch of pediatricians. What specific questions do you have?
if we do bill a 99213 along with 90658 and the 90471 will the insurance pay us less money on the office visit. i have been billing just the flu and the office code without the administration because sometimes insurances will decrease the payment considering it part of another procedure. what is your opinion on this
Hi Mary, typically we when we bill out an office visit 99213 with the flu vaccine 90658 and the admin 90471 our reimbursement rate for any of the services is not reduced. The multiple procedures rule does not usually apply to a vaccination. Have you checked your fee schedule with specific payers? What have the insurance representatives told you when you have called to follow up on this payment discrepancy? Please send us more information and we can try to point you in the right direction. Based on our experience, we have not had problems getting the proper (not reduced) reimbursement when billing out these 3 CPT codes together.
If my office wants to do a sort of flu express to administer the vaccination without having patients need to pay a copay, what diagnosis, procedure and encouter codes do use?
John sounds like you are going to have a flu clinic where you see a lot of patients at one time. We once had 400 patients come through in 2 hours at a flu clinic we held at our medical office. I worked for The Walt Disney Company in the past and know about crowd control and how to get people though a line fast. It worked well and the wait was only a couple of minutes.
For your clinic you still would bill these flu shots just as you would normally. Use 90471 (Immunization Administration) and 90657 (Influenza vaccine for children 6-35 months) or 90658 (Influenza vaccine for individuals 3 years or older) as appropriate for the patient’s age. For Medicare use G0008 for the administration code and the correct G code for the vaccine which is dependent on the manufacture (See above for codes). The V04.81 diagnosis typically goes with the flu shot.
Most insurance company no longer reimburse for a 99201 or 99211 so if they are just coming in for the flu shot you really don’t need to bill for the encounter. These encounter codes are the codes that usually cause the patient to have a copay. Billing just for the admin and vaccine should not cause the patient to have a copay. That has been our experience with our pediatric practice.
As always you should check with your insurance carriers for their specific billing, reimbursement and documentation rules.
Can we bill Office visit along with flu shot?
Are you asking about billing a “nurse visit” 99201 or 99211 with your flu shot? If so, most insurance companies stopped paying those codes with vaccines. If the patient is coming in for an unrelated problem such as for a rash for example, you are able to bill a higher level office visit code with the appropriate diagnosis for that problem and then bill the flu vaccine and admin code with a V04.81. Check with your insurance carriers on their specific rules.
Hello. I am getting ready to do roster billing for our flu shots this year. I found the Q code that we need to use and the fee schedule for that. I am having trouble finding the Indiana injection fee schedule. Can you tell me where to find that?
The best place to start is the CMS website.
Through the website you can then narrow your search parameters to look for your Specific Locality or Specific Carrier/MAC. Just enter in the codes you are looking for in the HCPCS Code Box and search and this should bring up the requested information. Otherwise, depending on your local Medicare Administrative Contractor (MAC), go directly to their website and they should also have an available fee schedule for you search.
Good morning Manny, I have a question I've been submitting flu shots to tricare and they have been rejecting because they want the national drug code, then sent them back with NDC but according to them thats not the correct one. Do you know what NDC would I use to bill for it? I also checked the websit cdc.gov could not find anything,
Help! thanks Mirna
Mirna, take a look at the package insert for the vaccine. The NDC number is specific to the manufacture, vaccine and strength. The proper NDC number for your vaccine should be on that insert. Use that number for your claim. One additional item to remember is that there is a specific format that you must follow when you put NDC numbers into your computer system. NDCs are in a 11-digit format and are usually seen in a 5-4-2 format. For example: 99999-9999-99. Sometimes on the package insert they are in 10-digit formats. Before entering the number into your computer system you must convert it to an 11-digit NDC or your claim will be denied.
Use the following methodology to convert your NDCs from 10-digits to 11-digits:
If 10-digit NDC format is: 4-4-2 9999-9999-99
Then add a zero (0) in: 1st position 09999-9999-99
Report NDC as: 09999999999
If 10-digit NDC format is: 5-3-2 99999-999-99
Then add a zero (0) in: 6th position 99999-0999-99
Report NDC as: 99999099999
If 10-digit NDC format is: 5-4-1 99999-9999-9
Then add a zero (0) in: 10th position 99999-9999-09
Report NDC as: 99999999909
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