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We are currently billing through an EMR, however, we do not have contracts with any insurance companies at this time. We are billing for an admn fee using cpt code 90471 (no modifier) to our Medicaid companies. MO Healthnet is the only company reimbursing us. United Healthcare and Home State Health always deny for various reasons. Missouri Care will sometimes pay it and other times deny it. My Director and I have been researching this and have came across a modifier 59 that could possibly be used. We are not sure if it is applicable to us or not. Does anyone else bill an admn fee to Medicaid companies and are being reimbursed? If so, please advise as to what cpt code and modifier you are using? Any help or advice will be most appreciated? Thank You!
We do get reimbursed for the admin fee — we use CPT Code 99211 with an EP modifier, and have not had any denials on that.
Are you billing the Admin fee for VFC vaccine for children 18 and under?
I use modifier SL on all my managed care companies for VFC administration codes (patients 0 to 18 yrs).
We do the same as Cindy, SL on all VFC 18 and under admin codes. We use specific admin codes for each vaccine.
Yes we are billing the admn fee for VFC vaccine for children 18 and under. We cannot bill 99211 for immunization admn fee due to the fact that we do not do height & weight on the patients. We use modifier SL with each vaccine code. Has anyone billed for the admn fee for immunizations using the cpt code 90471? Is anyone familiar with modifier 59? Thanks for the all the feedback. It is really helpful!
When billing VFC what your allowed to bill per shot is the admin fee since you dont bill for the vaccine. So for you to get anything else you will have to bill for an office visit 99211 you must do ht and wt. 90471 is what we use to bill commercial insurance per component for admin fee. So for VFC you cannot bill anything else but the admin per shot and an office visit 99211, from what I know. Hope that makes sense.
Medicaid only allows reimbursement of $5.27 per component for immunizations. That is your admin fee. The state gives you the free vaccine so the $5.27 per component is paid to cover your admin costs. That is all you are allowed to recoup. You cannot bill more than that by using other codes such as the 99211. Each code has guidelines for approved use. You have to follow those guidelines. Insurance companies will often pay for the use of the 99211 code. Just because they pay it does not mean you are using it appropriately. When they audit and see that the visit, the charting and the coding does not meet guidelines you will be responsible for that overcharge.
For adults you can bill through the pharmacy benefit for vaccines if you are using purchased vaccine. At that point you can try to bill Medicaid for the 90471 admin fee. I am not sure how well they pay on that though. We certainly do not get reimbursed well enough to cover all costs but we have to bill correctly. Hope this information helps.
“MO HealthNet enrolled providers must participate in the VFC Program administered by the Missouri Department of Health and Senior Services and must use the free vaccine when administering vaccine to qualified MO HealthNet eligible children. Providers may bill for the administration of the free vaccine by using the appropriate VFC Administration Codes. Providers must not use any additional administration procedure code. The MO HealthNet reimbursement for the administration is $5.27 per component.”—-http://manuals.momed.com/collections/collection_phy/print.pdf
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