Health Information Management

Flu shot in January, no pay til July

APCs Insider, January 21, 2003

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On Himinfo.com

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HIM VENDOR BUSINESS DIRECTORY

Flu's Clues:

Why was the Spanish influenza so named?

Who knows, since it likely originated in the United States. But unlike most flu viruses, it attacked the young and healthy the hardest. Yikes! That one virus killed 20 million to 40 million people back in 1918. (information compliments of CoolQuiz Network) These days, according to the National Center for Infectious Diseases, about 20,000 Americans die on average per year from the complications of flu.

NCID also estimated that approximately 10% to 20% of U.S. residents get the flu each year, and an average of 114,000 persons are hospitalized for flu-related complications.

Flu shot, anyone?

Another flu tip:

Prepare yourself for the onslaught of the flu bug by checking out our reader's question concerning reimbursement of the flu shot and other vaccines. There have been many changes in the last two weeks, in particular the fact that CMS is planning to delay payment of flu shot claims until July.

According to Julie Downey, CPC, CPC-H Ambulatory Coding Coordinator-HIM at University of Colorado Hospital, "CMS says it needs to get ready for shared systems changes, so the change will not be implemented by the standard system maintainers (SSMs) in January," she said. "So, we need to hold the claims until July."

Downey also said facilities who administer vaccines along with additional services that would be reported on the same claim as the vaccines, (during the period January 1, 2003, through June 30, 2003) may want to remove the flu or PPV vaccine and related charges from the claim in order to receive payment for the remaining services.

"You may send an adjustment bill that includes the vaccine and administration charges after the SSM implements the July release," she said.

There are many other requirements and changes you need to know about from PM A-02-129 and beyond--new information related to coding, billing, units of service, limits for certain services, and revenue code reporting information related to drugs that graduated from the pass-through payment list.

Stay up to date on the latest changes by reading APCAL and Briefings newsletters, and this Web site!


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The "Monitor" is a complimentary companion publication, with a specific mission: to provide answers to your tough questions about the APC regulations.

If you have a question about APC coding that you would like addressed in the "Monitor," post it on our Web site at himinfo.com. Each week, our team of experts answers questions that will appeal to the majority of readers. The elected questions and their corresponding answers are delivered to your inbox every Friday.


TODAY'S TOPICS:
Flu shot in January, no payment til July

ASK THE EXPERT Can we bill patients multiple copayments when they receive several treatments in a single day?

TIP OF THE WEEK Work with other organizations to prepare for transactions and code sets


Question:
I heard that Medicare is changing the way it pays for flu shots. Is this true?

Answer:
Starting January 1, 2003, CMS will no longer make payment based on the Outpatient Prospective Payment System (OPPS) for certain vaccines. Instead, payment will be based on provider type. Payment for the influenza virus and Pneumococcal Polysaccharide (PPV) vaccines and their administration provided in a hospital outpatient department, home health agency (HHA), and comprehensive outpatient rehabilitation facility (CORF) will be affected by this change. Hospitals (bill type 13X), and HHAs (bill type 34X) will be paid based on reasonable cost for the vaccines and their administration. CORFs (bill type 75X) will be paid based on the lower of the charges or 95 percent of the average wholesale price (AWP) for the vaccine.

Although the effective date of the change to payment for influenza and PPV vaccines and their administration is January 1, 2003, due to the need for shared systems changes, the change will not be implemented by the standard system maintainers (SSMs) in January.

As a result, if you receive claims with dates of service January 1, 2003, through June 30, 2003, containing any of the HCPCS for the influenza and PPV vaccines and their administration, hold the claims and do not release them for processing until your SSM has implemented the July release.

For more information, check out PM A-02-129.


Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.


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