Home Forums Discussions General Discussion Loss on pneumovax

Pneumovax reimbursement is about 63.00$ per shot from insurances- Medicare and private.

Doctors office has to pay a cost of $68.00. This has gone up every few mths from Merck as Pfizer has introduced the same vaccine at $110.00. My guess is that Merck will bring it that level in near future.

I believe most doctors are losing money if they give the shot on the same day of office visit. Not able to bill for administration costs and make up for loss. (Talk with your practice manager and analyze your pneumovax costs and reimbursements).

So give on a different day, then you get to charge for administration charges. Though inconvenient to patient due to billing regulations, doctors will not lose money on this essential vaccine.

Who says you can't bill the administration fee on the same day as an office visit?

Medicare does not allow admin fee on same day as office visit even with modifier, same with flu shots. I gave up and make pt. get from pharmacy - not worth hassle or loss of revenue when insurances do that.

And they wonder why people don't want to go into primary care. You get what you pay for.

with medicare adult patients if you use the G0008 for the flu shot and the G0009 for the pneumovax the administration fee is covered. with the shingle vaccine the 90471 is not covered and there is no G code for the zostavax, so the administration is not covered.

I am getting paid for admin fees on the same day as office visit. I think you must be doing something wrong. I am looking at a medicare EOB as we speak. On 8/14 I billed a 99214 reimbursed at $99.97. I billed a 90732 (pneumovax)reimbursed $65.77. I billed a G0009 (admin fee) reimbursed $22.65. All on the same patient on the same day.

I agree with Bill, same day visit admin fee with G codes for pneumovax and flu shots should be covered, I am getting paid too. just not the zostavax same day admin charge coverage because no G code.

All right Bill:

I will talk with my Biller again re: admin fee on same day of office visit.

What is your cost of pneumovax when you buy it?

You seem to be making up for the loss of vaccine cost by admin fee. Good for you.

joseph2,
you have to submit the G0008 and Q2037 as well as v04.81 at the time of visit and this should work for the flu shot. (medicare)

submit the G0009 and 90732 as well as the v03.82 for the pnuemovax and this should work. (medicare)

Tdap and shingles you will have to eat the admin because no G code.
Tdap 90715 90471 and v06.1 medicare or private

Private flu shot--90658 90471 and v04.81
Private pneumovax--90732 90471 v03.82

I would like to add the Q code is different depending on the brand of vaccine:
novartis-fluvirin--Q2037
sanofi-fluzone--Q2038
merck-afluria--Q2035
GSK-flulaval--Q2036

Also Zostavax 90736 90471 v04.89 (medicare or private)

medicare average reimbursement
Q2037- $13.65
Q2038- $13.30
Q2035- $11.54
Q2036- $8.78

You may have to consider referring them to a vaccine center if you can't even recoup your costs. Or write them a prescription to pick it up.

The CDC just changed the guidelines and the over-65 are to receive a Prevnar-13. The same pneumo admin code applies. Not sure what they are reimbursing, just started. Cost of Prevnar-13 is over $130.

You don't get reimbursed properly. At least not in Oregon.
I have almost given up trying to provide vaccines -- "meaningful use" be damned.

Medicare rules are that you are not reimbursed on date of E&M so congratulations if it is working for you - I have been screwed in the past so given up. The other thing is that since pharmacies are so into giving immunizations anyway that I just developed a rapport with local ones and get a report when one is given and my staff enter it in Health Maintenance.

Interesting thing about Shingles vaccine is that the reason there is no vaccine code for administering is that it is a Medicare D benefit which we can't bill. I am surprised you get even the cost of the vaccine as it should not pay under Part B.

Interesting thing about Shingles vaccine is that the reason there is no vaccine code for administering is that it is a Medicare D benefit which we can't bill. I am surprised you get even the cost of the vaccine as it should not pay under Part B. [/quote]

My modus operandum is to try to give the shingles between the ages of 60-65 so that I can charge an administration fee and get a little extra on the vaccine charge for privates.

For medicare I have patients sign a waiver since it is part D, charge the patient up front for the cost of the vaccine and a bit more, then have them pay at time of service, and then they can submit charge to medicare and get reimbursed later themselves. I can't charge an administration fee for the medicare patient. So the profit margin is about 25$ for medicare.

It is re-tramping on the grapes a bit to get more juice, but it is more of a convenience for the patient than a money maker.

Just got an EOB back. I did NOT get reimbursed for the G0008/Q2038/V04.81 given on the same day as the encounter.

Leslie,

I am wondering if it may be a regional difference, or my office manager says if one uses the nursing visit code 99211 with the flu shot and/or a 25 modifier with the 99211 the flu shot will not be reimbursed.

Just checked and I am getting reimbursed on my flu shots that are being given same day visit.

My understanding is that PCV-13 is recommended only for adults c significant immunocompromising conditions such as HIV and chemotherapy, though it is licensed for all adults. The ACIP is still recommending pneumovax for most adults 65 and older or those c chronic conditions such as DM, etc. I would stick c pneumovax for adults for now, unless I am unaware of a recommendation more recently than the June ACIP meeting.

So, the Medicare patients are over 65.

With respect to Medicare reimbursement for the influenza and pneumococcal vaccines, it is my understanding that it is INappropriate to charge a 99211 "nurse visit" with a modifier, since the administration is covered by G0008 and G0009. It is, however, appropriate to charge an E&M code with the -25 modifier for same-day services provided UNRELATED to the vaccines or to their administration with the appropriate ICD9 codes for that E&M service. Just be sure to not include then influenza vaccination ICD9 diagnosis code V04.81 as one of the diagnosis codes attached to the E&M code or the medicare carrier may consider the E&M code to be related to the vaccination and not a separately reimbursed service.


With respect to Pneumovax vs Prevnar-13, I agree with Bill that Pneumovax is the appropriate immunization for the general 65+ crowd. I've seen the ads for Prevnar-13 and have not yet found a justification for it as a more costly pneumococcal vaccine with questionably better efficacy. In order to avoid a complete government takeover of medicine, we need to start thinking in terms of cost-effectiveness and expect/demand that pharmaceutical companies justify newer and most often more costly alternatives to standard therapy. If not, we will suffer along with our patients. A marginal benefit can no longer be accepted as a reason to use a new therapy.

With respect to the initial post on this thread regarding taking a loss of $5.00 per shot for the Pneumovax ($63 reimbursement vs $68 cost), I have found that the best price is obtained by setting up an account and purchasing directly from Merck at MerckVaccines.com.

Likewise, for the high-dose Fluzone influenza vaccine for ages 65+, the best price is obtained directly from Sanofi at VaccineShoppe.com or VaxServe.com (both run by the manufacturer, Sanofi, although I can not understand why they have two sites with identical products and pricing, but different web layouts and different account numbers).

Both Sanofi and Merck offer prompt-pay discounts and Sanofi offers an online purchase discount.

I have gotten reimbursed for the g0009 and 90732 even when it is billed with a concomitant office visit e & m code..... and I have not had to use the -25 modifier on anything; total reimbursement is about $90 for the two, so you make a $20- $25 profit on each shot. (referring to Medicare specifically)

I know this is late to the party, but you can get the admin paid as well. You just need a 25 modifier on the office visit and a 59 modifier on the G-code admin.

I have a more detailed explanation on my blog. But I get them paid all the time.

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