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Dec 2nd, 2015 - pdhardy 3 

Getting denials for Medicare Flu & shot admin

All of our Medicare flu and shot admin codes are getting denied. Here are the details:
Flu cpt: 90662, and have included NDC, and amounts on claim
Admin cpt: g0008
Dx: Z23

The only thing I haven't tried is adding a modifier -25 to the shot admin CPT® since there are E&M, and wellness codes already on the claim. All the claims have been separated for payment by Noridian. The remark code is M81: you are required to code to the highest level of specificity and 16: claim lacks information or billing errors.

Anyone know what I am doing wrong? We only gave 10 doses of HD flu but all are denied which is a lot of money for a small practice.

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Dec 2nd, 2015 - LBAROGIANIS 250 

re: Getting denials for Medicare Flu & shot admin

List all the codes on the claim and if any, which ones were paid. I will run the codes through our Code editing software and let you know the outcome.

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Dec 2nd, 2015 - pdhardy 3 

re: Getting denials for Medicare Flu & shot admin

99214 -25 (paid) Dx M722, M7500, E780)
90662 (denied) Dx z23
G0008 (denied) Dx z23

This is one example and the simplest illustration. This one has more codes:
99213 -25 (paid) Dx I10, N19,
G0439 -25 (paid) Dx Z0000
G0101 -25 (Denied - lacks medical necessity) Dx z1239
G0008 (denied) dx z23
90662 (denied) dx z23

This one is just a shot no visit:
G0008 (denied) dx z23
90662 (denied) dx z23

Thanks for you help!

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Dec 2nd, 2015 - LBAROGIANIS 250 

re: Getting denials for Medicare Flu & shot admin

FIRST SCENERIO-90662 & G0008 NO RVU'S- THESE 2 CODES SHOULD NOT BE BILLED IN A PHYSICIAN SETTING

SECOND SCENERIO- G0101 BUNDLES WITH 99213, WILL NEED A DIFF MOD AND MOST LIKE RECORDS TO PROVE IT. -- NO RVU'S ON 90662 AND G0008- CAN'T BE BILLED IN A PHYSICIAN SETTING.

THIRD SCENERIO.. SEE ABOVE.

OUR MEDICARE (MAC) IS SAYING IT CAN'T BE BILLED IN A PHYSICIAN SETTING- THIS WAS THE SOFTWARE SAYS: Statutory Exclusion. These codes represent an item or service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No RVUs or payment amounts are shown for these codes, and no payment may be made under the physician fee schedule. (Examples are ambulance services and clinical diagnostic laboratory services.)

I HAVE NO IDEA WHY.. BUT HERE IS A WEBSITE THAT MIGHT HELP YOU. IF NOT TRY CALLING MEDICARE AND ASKING THEM OR CHECK WITH YOUR MAC. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf

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Dec 2nd, 2015 - pdhardy 3 

re: Getting denials for Medicare Flu & shot admin

Thanks for all the feedback. We were reimbursed last flu season just fine so can't figure out what has changed. The MLN document has been our reference b/c it is specific to the physician setting. We also follow the preventive handouts and flu is included there, too. Sounds like I need to contact the MAC and I will try to remove the -25 modifier and test that out so to speak. Again, Thanks!

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Dec 3rd, 2015 - irishjunebug 2 

re: Getting denials for Medicare Flu & shot admin

Hope it works for you:)
I should further explain that the E/M would be unrelated to the flu, the doctor addressed another dx with the patient. A patient coming in to just receive the flu would be the vaccine with administration only. Have a great day!

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Dec 2nd, 2015 - irishjunebug 2 

re: Getting denials for Medicare Flu & shot admin

When they are in to see the doctor (E/M) and in addition have a flu, pneumonia, or Hep B (any Medicare "G" administration), you do not need a 25 modifier on the E/M.

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