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NEW ORLEANS – It’s a widespread misconception among internists: Implementing an office-based adult immunization program is a potential financial sinkhole and just isn’t worth the hassle.
That’s utterly wrong, Jason M. Goldman, MD, declared at the annual meeting of the American College of Physicians.
“But it is virtually impossible to lose money giving vaccines,” he countered. “You may not be able to retire on it, but you’re certainly not going to break the bank – and you’re not going to lose money. And more importantly, you’re doing what’s best for the patient. This is one of the few times where the payers and the government recognize that doing what’s best for the patient can actually be profitable in running a practice.”
At the annual meeting of the American College of Physicians, he detailed how to create a successful immunization program, offering money-saving tips on vaccine purchasing and proper storage, as well as wading into the complexities of coding and billing – which, by the way, he insisted actually is not daunting.
“The vaccine schedule is not nearly as complicated as it appears,” according to Dr. Goldman. “Read through it. Look at it. As automatically as you say, ‘You’re over 50, get a colonoscopy,’ you can very quickly learn to look at a patient and say, ‘These are your diseases, this is your age, these are the vaccines you need.’
“This is not difficult. If I can do it, anyone can do it,” Dr. Goldman noted. “Start simple with one or two vaccines until you hit your comfort level; then you can get more advanced. I do the travel vaccines – yellow fever, typhus, the whole gamut. And it’s just as easy vaccinating for that as for any of the others.”
Why implement adult immunization?
Many internists send patients off to a pharmacy for their vaccinations. That’s simply not good medical care, Dr. Goldman said.
“We are the primary care doctors,” he said. “We are the ones who should be vaccinating our patients, for several reasons: It’s the standard of care. It’s good medical practice.”
And Dr. Goldman frequently doesn’t receive any reports from the pharmacies. That means patients come to his office and have no idea what vaccines they received.
“That’s not good documentation,” he cautioned. “And when patients go into the hospital, they all get Pneumovax every single week because the hospital isn’t keeping documentation.”
The bottom line with vaccinating: “Whether you’re in a small group, a solo practitioner, or in a large health system, the vaccine programs work. They prevent disease and save lives. It’s easy to incorporate into your practice. And it is profitable.”
How profitable?
Dr. Goldman has the answer. For a great many different vaccines, he has calculated his average cost for the needle, syringe, medical assistant, time in the room, and other factors involved in running his practice. He also knows from experience the average purchase price paid for a given vaccine, the typical reimbursement for that vaccine, plus the reimbursement for its administration, which is a separate yet necessary coding/billing item.
The typical net profit ranges from $21.50 for high-dose influenza vaccine to, at the top end, $47.41 for meningococcal group B vaccine (Bexsero) and $49.58 for recombinant human papillomavirus 9-valent vaccine (Gardasil-9).
Purchasing and storage considerations
Always buy vaccines directly from the manufacturer; it’s a better deal than going through a middleman, who’ll invariably take a cut out of what should be the physician’s profit.
Each of the major vaccine makers has a dedicated vaccine purchase website where a physician can sign up for an account and order the company’s vaccines. These include Merck (www.merckvaccines.com), Aventis (www.vaccineshoppe.com), Pfizer (www.pfizerprime.com), and GlaxoSmithKline (www.gskdirect.com).
You’ll get a discount by buying multiple different vaccines on the same order.
“You can defer payment of your invoice for several months,” Dr. Goldman explained. “You purchase the vaccines now, but you don’t have to pay for them until 3-4 months later. By then, hopefully, you’ll have received reimbursement. So, your cost is covered, and you have profit on the side.”
For paying promptly on the due date, the manufacturer will provide an additional discount. The easiest way to do that is to have the money automatically charged to a credit card on that date.
Also, the vaccine manufacturers’ staff are happy to provide reliably expert reimbursement guidance.
With a little experience, it’s easy to predict how many vaccines will be used per month, Dr. Goldman said. Order what’s needed, so there aren’t a bunch of vaccines expiring in the office.
“However, even if that does happen, all is not lost,” he noted. “You can call up the manufacturer, and many of them will take back unused or even expired vaccines for full credit to the account. So, again, you really can’t lose money.”
With regard to vaccine storage, don’t skimp on the refrigerator and/or freezer. Get a professional model. And follow the best practices as described in the Centers for Disease Control and Prevention toolkit.
“It’s really common sense: Don’t use a dorm-type refrigerator; don’t put food or beverages in there; make sure the vaccines are appropriately stored; check the temperature every day; make sure if you lose power, your building has a backup generator,” he explained. “If you train your staff the right way, they’ll be able to handle it so you don’t have to worry about it. You just have to look at the logs and make sure they’re doing it.”
Use standing orders
Studies show that standing orders result in higher vaccination rates.
“You’re empowering the nurses or other staff members to act within the full extent of their license,” Dr. Goldman said. “It takes the burden off the physician to have to do anything that can be delegated to other individuals to make sure patients get vaccinated.”
Coding and billing for commercially insured patients
All vaccines have the same ICD-10 diagnostic code: Z23. And each vaccine has its own CPT code. For example, 90750 for Shingrix, the new herpes zoster vaccine; 90715 for Tdap; and 90686 for quadrivalent influenza.
But there are two components to the CPT code for a vaccination: the individual vaccine code and the administration code.
If you give one vaccination to a non-Medicare patient, the administration code is 90471. If you give a second vaccination during the same visit, its administration code is 90472. If you give a patient, say, four vaccines during one visit, you would bill the first using the administration code 90471, and the others as 90472 times three units.
If the vaccines are being given during a legitimate office visit, the physician can bill for both by employing modifiers 25 and 59. Modifier 25 goes with the appropriate E/M code for the office visit; it serves to tell the coding system that other things are going on in addition to the billable office visit. Modifier 59 needs to be attached to both the specific vaccine code and the vaccine administration code for reimbursement to occur.
Billing for vaccines for all commercially insured patients go through the office’s normal claims process.
Immunizing Medicare patients
For patients under Medicare Part B, vaccines for influenza, pneumonia, and hepatitis B have their own individual G codes: G0008 for influenza, G0009 for a pneumonia vaccine, and G0010 for hepatitis B. If a Medicare patient also gets an additional vaccine other than one of those three during the visit, administration code 90472 is applied to it. Those G-code bills are also submitted through the office’s normal claims process.
Under Medicare, vaccines for herpes zoster, hepatitis A, and Tdap are a special case. They are considered drugs and are covered under Medicare Part D.
“To bill that, you have to tell Medicare that you’re acting as a pharmacy,” Dr. Goldman explained. “You go to www.mytransactRX.com. You request there to be seen as a pharmacy billing for a drug. You will then be able to receive direct payment into your bank account from your Medicare payer. It will also allow you to check out patient coverage, print out proof of coverage, and submit the claim through the portal.”
If the Medicare patient doesn’t have a drug plan for those vaccines, or if the information in the system isn’t up to date, it’s a good idea to download the Advanced Beneficiary Notice of Noncoverage from the Medicare website and have the patient sign it. It spells out what the patient’s financial responsibility could be.
“The ABN also protects you as a provider, because it shows you’re not trying to balance-bill the patient,” he noted.
Dr. Goldman implored his internist colleagues to stand up and become the stewards of adult immunization.
“Remember: Keep calm and vaccinate,” he urged.
He reported having no relevant financial conflicts.
NEW ORLEANS – It’s a widespread misconception among internists: Implementing an office-based adult immunization program is a potential financial sinkhole and just isn’t worth the hassle.
That’s utterly wrong, Jason M. Goldman, MD, declared at the annual meeting of the American College of Physicians.
“But it is virtually impossible to lose money giving vaccines,” he countered. “You may not be able to retire on it, but you’re certainly not going to break the bank – and you’re not going to lose money. And more importantly, you’re doing what’s best for the patient. This is one of the few times where the payers and the government recognize that doing what’s best for the patient can actually be profitable in running a practice.”
At the annual meeting of the American College of Physicians, he detailed how to create a successful immunization program, offering money-saving tips on vaccine purchasing and proper storage, as well as wading into the complexities of coding and billing – which, by the way, he insisted actually is not daunting.
“The vaccine schedule is not nearly as complicated as it appears,” according to Dr. Goldman. “Read through it. Look at it. As automatically as you say, ‘You’re over 50, get a colonoscopy,’ you can very quickly learn to look at a patient and say, ‘These are your diseases, this is your age, these are the vaccines you need.’
“This is not difficult. If I can do it, anyone can do it,” Dr. Goldman noted. “Start simple with one or two vaccines until you hit your comfort level; then you can get more advanced. I do the travel vaccines – yellow fever, typhus, the whole gamut. And it’s just as easy vaccinating for that as for any of the others.”
Why implement adult immunization?
Many internists send patients off to a pharmacy for their vaccinations. That’s simply not good medical care, Dr. Goldman said.
“We are the primary care doctors,” he said. “We are the ones who should be vaccinating our patients, for several reasons: It’s the standard of care. It’s good medical practice.”
And Dr. Goldman frequently doesn’t receive any reports from the pharmacies. That means patients come to his office and have no idea what vaccines they received.
“That’s not good documentation,” he cautioned. “And when patients go into the hospital, they all get Pneumovax every single week because the hospital isn’t keeping documentation.”
The bottom line with vaccinating: “Whether you’re in a small group, a solo practitioner, or in a large health system, the vaccine programs work. They prevent disease and save lives. It’s easy to incorporate into your practice. And it is profitable.”
How profitable?
Dr. Goldman has the answer. For a great many different vaccines, he has calculated his average cost for the needle, syringe, medical assistant, time in the room, and other factors involved in running his practice. He also knows from experience the average purchase price paid for a given vaccine, the typical reimbursement for that vaccine, plus the reimbursement for its administration, which is a separate yet necessary coding/billing item.
The typical net profit ranges from $21.50 for high-dose influenza vaccine to, at the top end, $47.41 for meningococcal group B vaccine (Bexsero) and $49.58 for recombinant human papillomavirus 9-valent vaccine (Gardasil-9).
Purchasing and storage considerations
Always buy vaccines directly from the manufacturer; it’s a better deal than going through a middleman, who’ll invariably take a cut out of what should be the physician’s profit.
Each of the major vaccine makers has a dedicated vaccine purchase website where a physician can sign up for an account and order the company’s vaccines. These include Merck (www.merckvaccines.com), Aventis (www.vaccineshoppe.com), Pfizer (www.pfizerprime.com), and GlaxoSmithKline (www.gskdirect.com).
You’ll get a discount by buying multiple different vaccines on the same order.
“You can defer payment of your invoice for several months,” Dr. Goldman explained. “You purchase the vaccines now, but you don’t have to pay for them until 3-4 months later. By then, hopefully, you’ll have received reimbursement. So, your cost is covered, and you have profit on the side.”
For paying promptly on the due date, the manufacturer will provide an additional discount. The easiest way to do that is to have the money automatically charged to a credit card on that date.
Also, the vaccine manufacturers’ staff are happy to provide reliably expert reimbursement guidance.
With a little experience, it’s easy to predict how many vaccines will be used per month, Dr. Goldman said. Order what’s needed, so there aren’t a bunch of vaccines expiring in the office.
“However, even if that does happen, all is not lost,” he noted. “You can call up the manufacturer, and many of them will take back unused or even expired vaccines for full credit to the account. So, again, you really can’t lose money.”
With regard to vaccine storage, don’t skimp on the refrigerator and/or freezer. Get a professional model. And follow the best practices as described in the Centers for Disease Control and Prevention toolkit.
“It’s really common sense: Don’t use a dorm-type refrigerator; don’t put food or beverages in there; make sure the vaccines are appropriately stored; check the temperature every day; make sure if you lose power, your building has a backup generator,” he explained. “If you train your staff the right way, they’ll be able to handle it so you don’t have to worry about it. You just have to look at the logs and make sure they’re doing it.”
Use standing orders
Studies show that standing orders result in higher vaccination rates.
“You’re empowering the nurses or other staff members to act within the full extent of their license,” Dr. Goldman said. “It takes the burden off the physician to have to do anything that can be delegated to other individuals to make sure patients get vaccinated.”
Coding and billing for commercially insured patients
All vaccines have the same ICD-10 diagnostic code: Z23. And each vaccine has its own CPT code. For example, 90750 for Shingrix, the new herpes zoster vaccine; 90715 for Tdap; and 90686 for quadrivalent influenza.
But there are two components to the CPT code for a vaccination: the individual vaccine code and the administration code.
If you give one vaccination to a non-Medicare patient, the administration code is 90471. If you give a second vaccination during the same visit, its administration code is 90472. If you give a patient, say, four vaccines during one visit, you would bill the first using the administration code 90471, and the others as 90472 times three units.
If the vaccines are being given during a legitimate office visit, the physician can bill for both by employing modifiers 25 and 59. Modifier 25 goes with the appropriate E/M code for the office visit; it serves to tell the coding system that other things are going on in addition to the billable office visit. Modifier 59 needs to be attached to both the specific vaccine code and the vaccine administration code for reimbursement to occur.
Billing for vaccines for all commercially insured patients go through the office’s normal claims process.
Immunizing Medicare patients
For patients under Medicare Part B, vaccines for influenza, pneumonia, and hepatitis B have their own individual G codes: G0008 for influenza, G0009 for a pneumonia vaccine, and G0010 for hepatitis B. If a Medicare patient also gets an additional vaccine other than one of those three during the visit, administration code 90472 is applied to it. Those G-code bills are also submitted through the office’s normal claims process.
Under Medicare, vaccines for herpes zoster, hepatitis A, and Tdap are a special case. They are considered drugs and are covered under Medicare Part D.
“To bill that, you have to tell Medicare that you’re acting as a pharmacy,” Dr. Goldman explained. “You go to www.mytransactRX.com. You request there to be seen as a pharmacy billing for a drug. You will then be able to receive direct payment into your bank account from your Medicare payer. It will also allow you to check out patient coverage, print out proof of coverage, and submit the claim through the portal.”
If the Medicare patient doesn’t have a drug plan for those vaccines, or if the information in the system isn’t up to date, it’s a good idea to download the Advanced Beneficiary Notice of Noncoverage from the Medicare website and have the patient sign it. It spells out what the patient’s financial responsibility could be.
“The ABN also protects you as a provider, because it shows you’re not trying to balance-bill the patient,” he noted.
Dr. Goldman implored his internist colleagues to stand up and become the stewards of adult immunization.
“Remember: Keep calm and vaccinate,” he urged.
He reported having no relevant financial conflicts.
NEW ORLEANS – It’s a widespread misconception among internists: Implementing an office-based adult immunization program is a potential financial sinkhole and just isn’t worth the hassle.
That’s utterly wrong, Jason M. Goldman, MD, declared at the annual meeting of the American College of Physicians.
“But it is virtually impossible to lose money giving vaccines,” he countered. “You may not be able to retire on it, but you’re certainly not going to break the bank – and you’re not going to lose money. And more importantly, you’re doing what’s best for the patient. This is one of the few times where the payers and the government recognize that doing what’s best for the patient can actually be profitable in running a practice.”
At the annual meeting of the American College of Physicians, he detailed how to create a successful immunization program, offering money-saving tips on vaccine purchasing and proper storage, as well as wading into the complexities of coding and billing – which, by the way, he insisted actually is not daunting.
“The vaccine schedule is not nearly as complicated as it appears,” according to Dr. Goldman. “Read through it. Look at it. As automatically as you say, ‘You’re over 50, get a colonoscopy,’ you can very quickly learn to look at a patient and say, ‘These are your diseases, this is your age, these are the vaccines you need.’
“This is not difficult. If I can do it, anyone can do it,” Dr. Goldman noted. “Start simple with one or two vaccines until you hit your comfort level; then you can get more advanced. I do the travel vaccines – yellow fever, typhus, the whole gamut. And it’s just as easy vaccinating for that as for any of the others.”
Why implement adult immunization?
Many internists send patients off to a pharmacy for their vaccinations. That’s simply not good medical care, Dr. Goldman said.
“We are the primary care doctors,” he said. “We are the ones who should be vaccinating our patients, for several reasons: It’s the standard of care. It’s good medical practice.”
And Dr. Goldman frequently doesn’t receive any reports from the pharmacies. That means patients come to his office and have no idea what vaccines they received.
“That’s not good documentation,” he cautioned. “And when patients go into the hospital, they all get Pneumovax every single week because the hospital isn’t keeping documentation.”
The bottom line with vaccinating: “Whether you’re in a small group, a solo practitioner, or in a large health system, the vaccine programs work. They prevent disease and save lives. It’s easy to incorporate into your practice. And it is profitable.”
How profitable?
Dr. Goldman has the answer. For a great many different vaccines, he has calculated his average cost for the needle, syringe, medical assistant, time in the room, and other factors involved in running his practice. He also knows from experience the average purchase price paid for a given vaccine, the typical reimbursement for that vaccine, plus the reimbursement for its administration, which is a separate yet necessary coding/billing item.
The typical net profit ranges from $21.50 for high-dose influenza vaccine to, at the top end, $47.41 for meningococcal group B vaccine (Bexsero) and $49.58 for recombinant human papillomavirus 9-valent vaccine (Gardasil-9).
Purchasing and storage considerations
Always buy vaccines directly from the manufacturer; it’s a better deal than going through a middleman, who’ll invariably take a cut out of what should be the physician’s profit.
Each of the major vaccine makers has a dedicated vaccine purchase website where a physician can sign up for an account and order the company’s vaccines. These include Merck (www.merckvaccines.com), Aventis (www.vaccineshoppe.com), Pfizer (www.pfizerprime.com), and GlaxoSmithKline (www.gskdirect.com).
You’ll get a discount by buying multiple different vaccines on the same order.
“You can defer payment of your invoice for several months,” Dr. Goldman explained. “You purchase the vaccines now, but you don’t have to pay for them until 3-4 months later. By then, hopefully, you’ll have received reimbursement. So, your cost is covered, and you have profit on the side.”
For paying promptly on the due date, the manufacturer will provide an additional discount. The easiest way to do that is to have the money automatically charged to a credit card on that date.
Also, the vaccine manufacturers’ staff are happy to provide reliably expert reimbursement guidance.
With a little experience, it’s easy to predict how many vaccines will be used per month, Dr. Goldman said. Order what’s needed, so there aren’t a bunch of vaccines expiring in the office.
“However, even if that does happen, all is not lost,” he noted. “You can call up the manufacturer, and many of them will take back unused or even expired vaccines for full credit to the account. So, again, you really can’t lose money.”
With regard to vaccine storage, don’t skimp on the refrigerator and/or freezer. Get a professional model. And follow the best practices as described in the Centers for Disease Control and Prevention toolkit.
“It’s really common sense: Don’t use a dorm-type refrigerator; don’t put food or beverages in there; make sure the vaccines are appropriately stored; check the temperature every day; make sure if you lose power, your building has a backup generator,” he explained. “If you train your staff the right way, they’ll be able to handle it so you don’t have to worry about it. You just have to look at the logs and make sure they’re doing it.”
Use standing orders
Studies show that standing orders result in higher vaccination rates.
“You’re empowering the nurses or other staff members to act within the full extent of their license,” Dr. Goldman said. “It takes the burden off the physician to have to do anything that can be delegated to other individuals to make sure patients get vaccinated.”
Coding and billing for commercially insured patients
All vaccines have the same ICD-10 diagnostic code: Z23. And each vaccine has its own CPT code. For example, 90750 for Shingrix, the new herpes zoster vaccine; 90715 for Tdap; and 90686 for quadrivalent influenza.
But there are two components to the CPT code for a vaccination: the individual vaccine code and the administration code.
If you give one vaccination to a non-Medicare patient, the administration code is 90471. If you give a second vaccination during the same visit, its administration code is 90472. If you give a patient, say, four vaccines during one visit, you would bill the first using the administration code 90471, and the others as 90472 times three units.
If the vaccines are being given during a legitimate office visit, the physician can bill for both by employing modifiers 25 and 59. Modifier 25 goes with the appropriate E/M code for the office visit; it serves to tell the coding system that other things are going on in addition to the billable office visit. Modifier 59 needs to be attached to both the specific vaccine code and the vaccine administration code for reimbursement to occur.
Billing for vaccines for all commercially insured patients go through the office’s normal claims process.
Immunizing Medicare patients
For patients under Medicare Part B, vaccines for influenza, pneumonia, and hepatitis B have their own individual G codes: G0008 for influenza, G0009 for a pneumonia vaccine, and G0010 for hepatitis B. If a Medicare patient also gets an additional vaccine other than one of those three during the visit, administration code 90472 is applied to it. Those G-code bills are also submitted through the office’s normal claims process.
Under Medicare, vaccines for herpes zoster, hepatitis A, and Tdap are a special case. They are considered drugs and are covered under Medicare Part D.
“To bill that, you have to tell Medicare that you’re acting as a pharmacy,” Dr. Goldman explained. “You go to www.mytransactRX.com. You request there to be seen as a pharmacy billing for a drug. You will then be able to receive direct payment into your bank account from your Medicare payer. It will also allow you to check out patient coverage, print out proof of coverage, and submit the claim through the portal.”
If the Medicare patient doesn’t have a drug plan for those vaccines, or if the information in the system isn’t up to date, it’s a good idea to download the Advanced Beneficiary Notice of Noncoverage from the Medicare website and have the patient sign it. It spells out what the patient’s financial responsibility could be.
“The ABN also protects you as a provider, because it shows you’re not trying to balance-bill the patient,” he noted.
Dr. Goldman implored his internist colleagues to stand up and become the stewards of adult immunization.
“Remember: Keep calm and vaccinate,” he urged.
He reported having no relevant financial conflicts.
REPORTING FROM ACP INTERNAL MEDICINE