FLU VACCINE INFORMATION 2014-2015 SEASON

By Sarah Howarth, Billing Manager

FLU SEASON 2014-2015

As the 2014-2015 Flu Season approaches, Practicefirst would like to remind clients to make sure their documentation and/or fee slips (Superbills) reflect the proper Administration CPT and Product CPT. 

A variety of influenza vaccine products are available, including (as of July 2013) five newly approved vaccines.  Please see the table below:

TABLE 1. Influenza Vaccines — United States, 2014–15 Influenza Season

CODING CORNER… SEPTEMBER 2014

By Lisa Kropp, Coding and Credentialing Manager

CMS Establishing four new HCPCS modifiers to define subsets of the -59 modifier

CPT Definition of -59 Modifier: Distinct Procedural Service

Purpose of Subsets:

  • Prevent Fraud & Abuse
  • Reduce number of reviews & appeals
  • Help providers assign this code properly

New Modifiers & Meanings:

  1. XE Modifier: Separate encounter i.e. a service that is distinct because it occurred during a separate encounter.
  2. XS Modifier: Separate structure i.e. a service that is distinct because it was performed on a separate organ/structure.
  3. XP Modifier: Separate Practitioner i.e. a service that is distinct because it was performed by a different practitioner.
  4. XU Modifier: Unusual Non-Overlapping Service i.e. the use of a service that is distinct because it does not overlap usual components of the main service

Takeaways:

  1. Implementation date is January 5, 2015
  2. CMS will continue to recognize the -59 modifier, but it should NOT be used in addition to these new modifiers because they are more descriptive.
  3. CMS may make the use of these modifiers mandatory when used to bill certain codes that are considered at high risk for incorrect billing.
  4. These modifiers are valid even before national edits are in place.  Providers are encouraged to use the more selective modifiers. MAC’s are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier.

 If you would like more information please contact Lisa Kropp; Coding & Credentialing Manager at 716.348.3904 or lisak@pracfirst.com

BILLING UPDATES – SEPTEMBER 2014

By Sarah Howarth, Billing Manager

Individuals who purchase insurance coverage through the NY State Dept. of Health and receive an advanced premium tax credit have a three-month grace period to pay their premiums.  Members must pay the first month’s premium before the three-month grace period begins.  During the first month of the three-month grace period, health plans are required to pay claims.  During the second and third months of the grace period, claims will pend for non-payment if the member has not paid the premium in full.  Claims will be denied if payment in full has not been made by the end of the third month.

To access a member’s grace period information for the insurance plans reflected on HealtheNet, follow these steps:

  1. Log on to wnyhealthenet.com
  2. Click on “Eligibility and Benefits”
  3. Enter Member’s information
  4. View “Plan Benefit Detail” and “Health Benefit Plan Coverage” sections for information on grace period status and claim pend dates.

INDEPENDENT HEALTH

To fulfill the terms and conditions of their contract with the Center for Medicare & Medicaid Services and the New York State Department of Health, Independent Health has created a Disclosure of Ownership and Control Attestation Form.  Providers will only be required to complete this form upon specific request from Independent Health.  If you should receive this request, please complete and return the form within 21 calendar days.

For Billing questions, please contact Sarah Howarth at 716-348-3923 or sarahh@pracfirst.com<

Vaccine

Trade

name

Manufacturer

Presentation

Mercury content
(µg Hg/0.5 mL)

Ovalbulmin content
(μg/0.5 mL)

Age indications

Route

Inactivated Influenza Vaccine, Quadrivalent (IIV4), Standard Dose Fluarix® Quadrivalent GlaxoSmithKline 0.5 mL single-dose prefilled syringe ≤0.05 ≥3 yrs. IM
FluLaval® Quadrivalent ID Biomedical Corporation of Quebec (distributed by GlaxoSmithKline) 0.5 mL single-dose prefilled syringe ≤0.3 ≥3 yrs IM
5.0 mL multidose vial <25 ≤0.3 ≥3 yrs IM
Fluzone® Quadrivalent Sanofi Pasteur 0.25 mL single-dose prefilled syringe **** 6-35 mos. IM
0.5 mL single-dose prefilled syringe **** ≥36 mos. IM
0.5 mL single-dose vial **** ≥36 mos. IM
5.0 mL multidose vial 25 **** ≥6 mos. IM
Inactivated Influenza Vaccine, Trivalent (IIV3), Standard Dose Afluria® bioCSL 0.5 mL single-dose prefilled syringe <1 ≥9 yrs.††† IM
5.0 mL multidose vial 24.5 <1 ≥9 yrs.††† IM
Fluarix® GlaxoSmithKline 0.5 mL single-dose prefilled syringe ≤0.05 ≥3 yrs. IM
FluLaval® ID Biomedical Corporation of Quebec (distributed by GlaxoSmithKline) 0.5 mL single-dose prefilled syringe ≤0.3 ≥3 yrs IM
5.0 mL multidose vial ≤25 ≤0.3 ≥3 yrs IM
Fluvirin® Novartis Vaccines and Diagnostics 0.5 mL single-dose prefilled syringe ≤1 ≤1 ≥4 yrs. IM
5.0 mL multidose vial 25 ≤1 ≥4 yrs. IM
Fluzone® Sanofi Pasteur 0.5 mL single-dose prefilled syringe **** ≥36 mos. IM
5.0 mL multidose vial 25 **** ≥6 mos. IM
Fluzone® Intradermal§ Sanofi Pasteur 0.1 mL prefilled microinjection system **** 18-64 yrs. ID**
Inactivated Influenza Vaccine, Trivalent, Standard Dose, Cell Culture-based (ccllV3) Flucelvax® Novartis Vaccines and Diagnostics 0.5 mL single-dose prefilled syringe ††† ≥18 yrs.††† IM
Inactivated Influenza Vaccine, Trivalent (IIV3), High Dose** Fluzone® High-Dose†† Sanofi Pasteur 0.5 mL single-dose prefilled syringe **** ≥65 yrs. IM
Recombinant Influenza Vaccine, Trivalent (RIV3) FluBlok® Protein Sciences 0.5 mL single-dose vial 0 18-49 yrs. IM
Live-attenuated Influenza Vaccine, Quadrivalent (LAIV4) FluMist® Quadrivalent§§ MedImmune 0.2 mL prefilled intranasal sprayer ≤0.24 (per 0.2 mL) 2-49 yrs. IN