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Deborah Howell (Host): . Hello and welcome to the American College of Osteopathic Internists podcast, Docs Off the Clock. Juggling the business of medicine and caring for patients means doctors always seem to be on the clock. Docs Off the Clock features some of today's best voices in healthcare with tips on how to live a better, balanced life. Thanks for stopping by today. The purpose of this podcast is to begin to explore vaccine administration in the office. We are joined today by Jill Young, the Principal of Young Medical Consulting, LLC, a company founded to meet the education and compliance needs of physicians and their staff. Jill has over 30 years of billing and coding experience working in all areas of medical practice and serves as the Practice Management Consultant to the ACOI. Welcome Jill.

Jill Young, CPC, CEDC, CIMC (Guest): Thank you so very much and good day to everyone.

Host: Yeah, lovely to have you. Let's jump on in. Why is government pushing administration of the COVID-19 vaccine out to physicians' offices?

Jill: Well, from my perspective in everything that I have read, there really isn't a given rationale. But if you look at the programs that are out there, the government has programs for patients with Medicare, they have programs for uninsured, and then we want to kind of capture everybody else that has insurance. And it just seems to make sense that once we get past that mass immunization that we've seen, that on a more, if you will, normal basis, like the flu shot that it goes out to the doctors' offices. They're going to be the ones to counsel their patients on you know, if this becomes a regular thing like flu shots do. Is it just something that it's just going to be a lot easier to work with your regular family or a primary care physician?

Host: Sure, as you said, that just makes sense. And then what's the reimbursement amount for this administration?

Jill: Well, the good news is they raised it. It is $40 per dose. It had been as low as 18 for some of the doses. But, with the assumption we're talking only for the administration, for dose one and two, so that's both the Pfizer and the Moderna where you have two doses and then Johnson and Johnson, where you only had one it's $40. And that's just administration. Now with the new booster, I've seen two different numbers. I've been unable to confirm as of this moment, I've seen 35 and also $40 reimbursement for that booster shot. So, that's a good thing because it's not as simple as some injections are. And so I think that $40 is a fair amount for the amount of work and staff time that you have to spend with this.

Host: Sounds good. And are there specific codes to use for different vaccines?

Jill: Well, you know, I think that the people that make up codes have gotten very smart in some ways. They have come out with both codes, if you would bill for the vaccine serum, which right now, no one is because everyone's being given the serum, but the codes that are assigned to each serum, which would line up, for example, with the Pfizer, they end in two digits. And those two digits are incorporated in the administration code for the first dose, for the second dose and for the third or booster dose. So, that someone looking at a claim form would be able to say, oh look, this is 0002A. That tells me that it's the second dose of the Pfizer.

And all this information is easily found on the cms.gov COVID section of the website. So, there's a consistency in making it easy, which is something that's been nice that we've seen with CPT over the years, where we're getting better consistency and logic in their codes. So, yeah, that's been the nice part that they released these codes. Again, they've released CPT codes for the vaccine serum, if you will, when we don't even need those codes yet. And yet they've released those codes and they are connected or, there's a logic consistent with the administration code. So that's pretty cool.

Host: That's a little impressive

Jill: Not bad at all.

Host: And what are the levels of supervision required for this administration?

Jill: That's where we're going to have to put our thinking caps on I think. Because for vaccine supervision in general, if you will, you don't need to have a physician order. You don't need to have physician supervision. That's why you can go to the Walmart or the CVS to get your flu vaccine. But the thing with the COVID vaccine is there is that cautionary 15 minute watch. Now, whether they're going to change that over time, we don't know. So, if we go with the letter of the law from Medicare, the level of supervision, we don't have to have a physician there, by the same token, especially for people that are receiving their first doses, where we do watch them; we want to be sure that we have at least some kind of trained clinical staff there that are prepared to handle if there is a problem.

I've worked in some vaccination clinics from my previous life where I gave immunizations, years and years ago, when the call went out, I started to work at a mass vaccination clinic in an old department store at the drive-through bays that they had used for car stuff. And so I was literally giving COVID vaccines to people in their cars and it was winter. It was cold. In doing that, we didn't have any doctors on site unless they happened to be volunteering. But we did have a designated medical person just in case anybody had trouble. And we had in the many, many shifts that I worked, I think we had a couple of people that got a little woozy. I have a feeling, it was more anxiety, giving hundreds of shots that I did. Some people, in that environment and they can see other people getting their shots a little bit. They get pretty anxious. And so I think it was more that than any true reaction. But so being smart, I would say at least until we get any further guidance, the official Medicare rules say no level of supervision is required, which means someone could be in the office and just do it.

I'm not sure that I would recommend that, but again, where we are with the rules as of today is that that level of supervision there just isn't a high level of required. But common sense, I think says a little more.

Host: Sure. And I would just say to anybody who's like me, who tends to get syncope from time to time, which means a little bit of fainting action; when you look at the needle, just don't look, and I always tell the nurse, you know what, I don't need to know what you're doing. I'm going to look the other way and I'm going to think happy thoughts, and then it doesn't happen to me. But if you look and they explain and they go now I'm going in, you know, then, then, you know, it tends to raise the level of anxiety.

Jill: I think that's so true, you know, after having, not given a shot for many, many years, everybody develops their own little routine, if you will. And one of the things that kind of drives me a little crazy is watching when we see people on the news giving shots and they're pinching arms. And it's like, no, you want that muscle relaxed.

And so I had this little routine of, okay, relax your shoulder, see, see how relaxed your arm is right now. And nice and soft so that when I do this, you didn't even know I was there. Kind of like for you, I sneak up on it. But my favorite part was I brought fun band-aids. Especially people that were super nervous, I'd say, you know, your biggest decision today is to decide what color bandaid you want.

Host: Oh, that's That is totally brilliant. Give me the SpongeBob one, please. And I'm good to go.

Jill: I had emojis and smiley faces. Let me tell you.

Host: Oh, perfect. Now let's talk about working at that mass vaccination site again. What unique insights did that kind of work give you and looking at what this rollout to vaccinations being given in the offices means?

Jill: We had a dedicated pharmacist that was in charge of the vaccine up until the point where we would draw it up. Because I was also in the group that would draw up the serum into syringes. But there was a trained pharmacist that would reconstitute the Pfizer. And that includes, thawing it down, for the Moderna, dealing with the temperature issues. When we went out to some of the schools, she had a cooler, she had temperature stuff with it. I have not specifically seen at what point, if you will, they're giving it to doctors' offices. Whether they've already done most of that. But for example, with the Pfizer, when you reconstitute it, you have six hours.

That's all you have. And so if you think about a doctor's office, if we forget all of the refrigeration stuff, okay, you've got six hours to give this vile of shots. Well, number one, you don't want to have a lot of shots, when you don't know if you're going to have people. And I talked to a friend of mine the other day from Iowa, and he said that he had said to his staff because they're doing they're rural. And he said, how many shots did we have today? And she said we had 50. So, that meant they had five vials. He said, how many shots did we give? And she said, eight. And in the early days, especially at these mass clinics where you're trying to plan, and that's why they want appointments, so that they can prepare stuff and then have to waste it, or sometimes late in the day, once the government eased some of their restrictions, you're 20 minutes from closing and you're like, okay, we still got 50 doses. You're calling people saying, hey, can you come down now? Cause that was in the days when people were desperate for appointments.

And I think we're going to kind of see that again, as we look at getting the boosters that we're going to have kind of a resurgence of that and those people where I worked, did that fine balance of how many shots do we get ready? I mean, I remember one night, literally the girls like, oh, somebody came in the door, I got to go do one more vile, which meant five more shots or for Moderna, 10 more shots.

So, think about a doctor's office and now you have to have that quality control. And I'm sorry, that takes a brain that operates a little differently, I think, to be able to say, okay, I'm going to do this. You know what? I only have one more person coming in today. I'm going to see if they can come in tomorrow. Cause then I don't have to waste this whole thing. It's a different level. It's a critical thinking at a different level, I think in the offices. And I'm not saying it can't happen. I'm just saying my advice to doctors' offices, if you're thinking about doing this, two things, go on the cms.gov site and see what you have to do to sign up, to do this.

Cause there are some requirements that you have that you have to take everybody. And that includes anybody, any insurance. You have to know the billing requirements and probably one of the trickiest ones to me is people that have a Medicare advantage plan. So you think, oh, I bill the Medicare advantage plan. No, you have to bill Medicare. So, that means you're going to have to go out and get their unique Medicare number when you're used to billing their unique Medicare advantage number. So that's a little extra work. And so you have to make sure you know, what you're getting into and as long as you do, and you have the staff that can handle that, think about that.

If you, on a Thursday afternoon, cause the doctor doesn't work that day and you line up a bunch of vaccines or, with vacations and holidays, or maybe even on a Saturday, just set it up and make appointments. It would be a great practice builder as well. But again, you have to have someone with a critical thinking process that can work their way through that and in doing so, make it a successful venture.

I hate that phrase win-win but I'll say that here that it becomes a win-win for the patient and for the practice, because again, at $40 a reimbursement, and one of the things I did forget to say is they are also reimbursing an extra $35, if you're going into the home under certain conditions. So, if you're in a primary care internal medicine practice where your doctor is in any way, making house calls, again, you need to look at what the requirements are, but we're talking $75 a shot now for administration alone.

Host: Sounds like the administration really, really wants people vaccinated.

Jill: They do. And I think that the dollars that they've put behind it shows that, because again, if you've got staff that has to do, in essence, have someone dedicated to taking care of this, not dedicated as in eight hours a day, but rather dedicated from being some one person being in charge. You're going to see an increase in your staff time, at least at some level, but you know what I'll bet if you asked, I bet most offices right now, if someone's listening to this, the doctor goes, so you know who that is that Susie are there. She's really good at that kind of stuff. So, just be informed about what you're getting into, be informed about what the process is. Then I think that just opens up the gates because like here, where I live, all of the mass vaccination places have nearly shut down. Now, the one that I worked at, we went inside that old closed down store, and now we're back outside. And now they're talking about okay, with the possibility of boosters. So, we're going to be back outside either in the heat or the cold.

And they're also talking about the possibility of doing flu shots too. So, you wouldn't give them at the same time cause there's restrictions there. But again, get people vaccinated, flu, COVID, whatever it takes. But, if you don't happen to have a six bay ex-car place available, there's other places that you can get, but I just think they're working as best they can. I mean, again, we went to the high school, went in the gym of the high school. So, you just have to be creative to take care of it, but I think it's a great idea. I think it's entirely possible in a physician's office, but is not as simple as just giving flu shots, there are controls that you have to work with. And so I just want to be sure people know that part, but again, with the reimbursement, I think it makes it worthwhile.

Host: Well, Jill, it's been great to have you on with us today. All this excellent information, lots to consider. Thank you so much for your time and your expertise.

Jill: Thank you so much. It was delightful to speak with you.

Host: And thank you for spending a little time with us today. We look forward to future podcasts where we'll continue to explore issues of importance to you. For more information, please contact the ACOI directly at 1-800-327-5183. Or check out our website at www.acoi.Org. You can also email us at acoi@acoi.org, and be sure to follow us on Facebook, LinkedIn, and Twitter. Until next time, be well.