Forum - Questions & Answers

Apr 6th, 2022 - Nettie1113

Claim Billing question

I just had a claim requesting reimbursement because I billed it as follows: 99213 - Office Visit 85610 - PT/INR 90756 - Influenza 21-22 G0008 - administer flu shot UHC Commercial insurance apparently "bundles' the Influenza shot and the office visit and are requesting reimbursement for the office visit. I don't see this "bundling" on any documentation at and they can't "prove" it to me, just this is their policy. What leg do I have to stand on??

Apr 11th, 2022 - ChrisW   256  1 

re: Claim Billing question

Without knowing the exact plan you are referring to there are a few things going on here. 
You may consider reporting the Modifier 25 on the visit if the E/M service was provided on the same day as the vaccine, (this does not include preventive medicine E/M services) if the patient was seen for a different reason with a chief complaint, other than coming in for a vaccine. In this case, the diagnosis should be different on the office visit, consider using use an encounter code such as Z23 for influenza and the administration.   UHC does have a policy on Vaccinations, stating the following. " These vaccines may be reimbursed regardless of the setting in which they are furnished. In addition, the administration fee for these vaccines is also eligible for payment",  referring to 90756.     In addition, UHC states the following in one of their policies; " Immunizations are generally excluded from coverage under Medicare unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment or tetanus antitoxin or booster vaccine. In the absence of injury or direct exposure, preventive immunizations (vaccination or inoculation) against such diseases as smallpox, typhoid, and polio, are not covered. In cases where a vaccination or inoculation is excluded from coverage, the entire charge will be denied (such as office visits which are primarily for the purpose of administering a non-covered injection)."This is from a UnitedHealthcare Advantage plan. So it will depend on the plan as well as the diagnosis submitted. If the member was just seen for a vaccine, they may not pay for the office visit. I would suggest reviewing the policies on vaccines on the specific plan you are billing, it may simply be the issue of using the 25 modifier, if applicable, hope this helps.UHC Medicare Advantage PolicyNational Adult and Influenza Immunization Summit.

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