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Medicare immunization billing

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solids19:
Specs:
Noridian MAC
Not a Mass Immunizer
Not a Roster Billing
Not RHC or FQHC facility

CPT/HCPCS: 90674 (Influenza)/G0008 (Administration)
Dx: Z23
TOB: 131
Condition code: A6

Medicare Denial RARC code: 45

Claims submitted individually via UB-04 w/TOB 131.
We are billing Medicare for immunization, example seasonal influenza.  Got Medicare Remittance Advice denial code of RARC-45, charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.  Not clear what we are missing, any suggestions/ideas? Thanks in advance!

Michele:
I wasn't aware that facilities could bill for administration of influenza vaccine.  Doesn't this have to be billed on a CMS 1500?

solids19:

--- Quote from: Michele on March 21, 2019, 09:41:27 AM ---I wasn't aware that facilities could bill for administration of influenza vaccine.  Doesn't this have to be billed on a CMS 1500?

--- End quote ---

Hospital Billing. Providers do not own any of the vaccines. 

CMS Medicare Learning Network (MLN)
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf  (page 9) show various Facility Types and TOB.

Claims were reported as instructed with Revenue Codes:
0636 – vaccine
0771 – vaccine administration

Michele:
Well ya learn something new everyday!

Does the reason code 45 have a letter in front of it?  I'm not finding any RARC code with just 45.  Maybe an "M" or an "N"?

solids19:

--- Quote from: Michele on March 22, 2019, 11:47:39 AM ---Well ya learn something new everyday!

Does the reason code 45 have a letter in front of it?  I'm not finding any RARC code with just 45.  Maybe an "M" or an "N"?


--- End quote ---

It's CARC rather RARC.

https://med.noridianmedicare.com/web/jeb/topics/claim-submission/reason-code-guidance (Noridian Medicare)
http://www.x12.org/codes/claim-adjustment-reason-codes/ (Washington Publishing Company)

Ex) Billed Charges $15, Allowed $15, Contractual Adjust $15, Paid Amount $0.  Reason/Remark Codes (CARC-45).  Both vaccine & vaccine administration adjusted in the same manner. 

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