Does Medicare cover the hepatitis B vaccine for all Medicare beneficiaries?
No, Medicare covers the hepatitis B vaccine for certain beneficiaries who are at intermediate to high risk for the hepatitis B virus (HBV). These individuals include health care professionals who have frequent contact with blood or blood-derived body fluids during routine work, those with End-Stage Renal Disease (ESRD), persons who live in the same household as an HBV carrier, and persons diagnosed with diabetes mellitus. Other situations could qualify a beneficiary as being at intermediate or high risk of contracting HBV. Medicare beneficiaries who are currently positive for antibodies for hepatitis B are not
eligible for this benefit.
Seasonal Influenza Virus Vaccine Administration Code:
G0008 Diagnosis Code: Z23
90630 – Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use
90653 – Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use
90654 – Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use
90655 – Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use
90656 – Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use
90657 – Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use
90660 – Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use
90661 – Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
Pneumococcal and Seasonal Influenza Virus Vaccines received during the same visit Administration Codes:
G0008: Influenza Virus
G0009: Pneumococcal Diagnosis Code: Z23
Use seasonal influenza virus and pneumococcal vaccine codes Follow Medicare coverage requirements for seasonal influenza virus and pneumococcal vaccines
Influenza, Pneumococcal, and Hepatitis B Vaccinations
Influenza (Flu) Virus Vaccine
CPT and payable Diagnosis (DX)
Q2035 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirun)
Q2038 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)
The article is based on Change Request (CR) 7234 which establishes separate billing codes for each brand-name influenza vaccine product under Common Procedure Terminology (CPT) code 90658 and describes the process for updating the new specific Healthcare Common Procedure Coding System (HCPCS) codes and their payment allowances for Medicare during the 2010-2011 influenza season.
Background
CMS has created specific HCPCS codes and payment allowances to replaceCPT code 90658 for Medicare billing purposes for the 2010-2011 influenza season.
CPT Code Short Description Long Description
90658 Flu vaccine, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Take Note: CPT 90658 describes the regular dose vaccine that is supplied in a multidose vial for use in patients over 3 years of age. For dates of service on or after October 1, 2010, HCPCS codes Q2035, Q2036, Q2037, Q2038 and Q2039 (as listed in the table above) will replace the CPT code 90658 for Medicare payment purposes during the 2010 – 2011 influenza season. However, these HCPCS codes will ot be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized.
This instruction does not affect any other CPT codes. It is very important to distinguish between the various CPT and HCPCS codes which describe the different formulations of the influenza vaccines (i.e. pediatric dose, regular dose, high dose, preservative free, etc.). As a reference, the quarterly Part B drug pricing files includes a set of National Drug Code (NDC) to HCPCS crosswalks available online at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-BDrugs/McrPartBDrugAvgSalesPrice/index.html on the Centers for Medicare & Medicaid Services (CMS) website.
Payment
The Medicare Part B payment limits for influenza vaccines are 95 percent of the
Average Wholesale Price (AWP) except where the vaccine is furnished in a setting
that follows a cost-based or prospective payment system under Medicare. For
example, where the vaccine is furnished in the hospital outpatient department, Rural
Health Clinic (RHC), or Federally Qualified Health Center (FQHC), payment for the
vaccine is based on reasonable cost.
Influenza – V04.81
Pneumococcal – V03.82
Influenza and Pneumococcal – V06.6
If the nurse supply a medically necessary, important, separately identifiable evaluation and management (E/M) service in addition to the flu shot, it may be appropriate to yield 99211 with modifier -25 attached in addition to 90658.
What’s New?
Effective for dates of service on or after October 1, 2010, Healthcare Common Procedure Coding System (HCPCS) codes Q2035, Q2036, Q2037, Q2038, and Q2039 will replace the Current Procedural Terminology (CPT) code 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) for Medicare payment purposes during the 2010-2011 influenza season; however, these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized.
Billing
In general, it is inappropriate for a provider to submit two claims for the same service on the same date. For dates of service between October 1, 2010 and December 31, 2010, the CPT 90658 and the Q-codes will be valid for billing; however, providers may not bill Medicare for both the CPT 90658 and any of the Q-codes for the same patient for the same date of service. Thus, if a provider vaccinates a beneficiary on any date between October 1, 2010 and December 31, 2010, the provider may either bill Medicare immediately using CPT 90658, or hold the claim and wait until January 1, 2011 to bill Medicare using the most appropriate Q-code. If a claim has already been submitted and processed using CPT 90658, then there is no need to use the Qcode for that same service.
For dates of service on or after January 1, 2011, providers may only bill Medicare for one of the HCPCS codes that appropriately describes the specific vaccine product administered.
An administration code should always be reported in addition to the vaccine product code. Note: Third party payers may
have specific policies and guidelines that might require providing additional information on their claim forms.
ACIP recommends not using FluMist during the 2016–17 influenza vaccination season.
In 2010, ACIP recommended that Afluria not be used in children younger than age 9 years. If no other age-appropriate IIV is available, Afluria may be considered for a child age 5 through 8 years at high risk for influenza complications, after risks and benefits have been discussed with the parent or guardian. Afluria should not be used in children younger than age 5 years. This recommendation continues for the 2016–2017 influenza season.
Afluria is approved by the Food and Drug Administration for intramuscular administration with the PharmaJet stratis Needle-Free Injection System for persons age 18 through 64 years.
Medicaid and Medicaid MCOs cover seasonal influenza immunizations through the VFC program for eligible children. The vaccine is provided by the state and the dministration service is paid based on the vaccine code reported. Report the specific flu vaccine code with the SE modifier appended to the CPT code. The allowed reimbursement is $23.28 effective January 1, 2013.
B. Medicaid covers the flu vaccine only for adults. Vaccine CPT codes listed in the Medicaid fee schedule are 90656, 90655, 90658 and 90660.
C. Coverage from Medicaid MCOs will vary by plan. However, if the billing entity is participating, most flu immunizations will be covered and should be billed with the vaccine code and administration code.
Flu season vaccination has arrived. Flu and pneumonia vaccines are annual covered benefits for all Better Health Medicaid members. The pneumonia vaccine requires prior
Influenza and pneumonia vaccinations are also covered through our network pharmacies. Members should check with their pharmacist concerning the availability and administration of both vaccines.
Better Health reimburses participating providers for influenza and pneumococcal vaccinations as follows:
* Birth – 18 year old members – participating providers receive vaccines free for Medicaid members from birth through 18 years of age by joining the Federal Vaccines for Children Program (VFC). Better Health will reimburse providers a $10 administration fee for the vaccine when billing with the administration codes G0008 for the flu vaccine and G0009 for the pneumococcal vaccine.
* 19- 20-year old members – Participating providers will be reimbursed for the cost of the vaccine and the administration fee of $10.00 by billing with the dministration code G0008 (flu vaccine) or G0009 (pneumococcal vaccine), modifier HA and the applicable procedure code below:
CPT Codes Modifier 19-20 Flu and Pneumonia Vaccines for 19-20 Year Olds Administration code G0008 Flu and G0009 Pneumonia Payment Limit (19-20)
90656 HA Influenza virus vaccine, intramuscular, preservative free $21.92
21years and older – Participating providers will be reimbursed for the cost of the vaccine and the administration fee of $10.00 by billing with the administration code G0008 (flu vaccine) or G0009 (pneumococcal vaccine), and the applicable procedure code below:
CPT Codes Flu and Pneumonia Vaccines for 21 Year Olds and Older Administration code G0008 for Flu and G0009 for Pneumonia Payment Limit (21+)
90656 Influenza virus vaccine, intramuscular, preservative free $13.88
Tips for Successful Processing of Flu Vaccines on the Pharmacy Benefit
The following will help a pharmacy obtain a paid flu vaccine claim for our Members:
1. Utilize a covered product below with the appropriate NDC number
Pneumococcal and Seasonal Influenza Virus Vaccines received during the same visit Administration Codes:
G0008: Influenza Virus G0009: Pneumococcal Diagnosis Code: Z23 Use seasonal influenza virus and pneumococcal vaccine codes Follow Medicare coverage requirements for seasonal influenza virus and pneumococcal vaccines
When a beneficiary gets both the seasonal influenza virus and pneumococcal vaccines on the same visit, do I continue to report separate administration codes for each type of vaccine?
Billing Medicare for Immunizations
Medicare does not require for coverage purposes that a doctor of medicine or osteopathy order the pneumococcal or influenza virus vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision.
The administration of influenza virus, pneumococcal, and hepatitis B vaccines, (HCPCS codes G0009, G0008, and G0010), though not reimbursed directly through the Medicare Physician Fee Schedule, is reimbursed at the same rate as CPT code 90782 for the year that corresponds to the date of service of the claim. See Appendix A for a table of “Immunization Codes Used to Bill Medicare.” Appendix B lists codes for billing non-Medicare patients.
Payment allowances for codes for products that have not yet been approved will be provided when the products have been approved and pricing information becomes available to CMS.
The payment allowances for pneumococcal vaccines are based on 95 percent of the AWP and are updated on a quarterly basis via the Quarterly Average Sales Price (ASP) Drug Pricing Files.
The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the AWP as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally Qualified Health Center
Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.
Billing for Additional Services
A provider may bill for additional reasonable and necessary services in addition to the administration of pneumococcal, influenza, and/or hepatitis B vaccines. For example, a provider can bill HCPCS G0008 to report the administration of the influenza vaccine in addition to other services performed during the same visit, including an evaluation and management (E/M) service.
Each additional service should always be justified with an appropriate diagnosis code.
State. VFCA PCA/SOP set up for LA and TX that will require serum and admin codes update when LA and TX update their lists
The vaccine code(s) and administration code(s) may be submitted on separate claims, but the claims must be for the same date of service by the same provider and the number of units for each must match. Excessive units of either code(s) will be denied – i.e. 90658 (vaccine) – 1 unit
90471 (administration) – 1 unit
90696 (vaccine) – 1 unit
90472 (administration) – 2 units – 1 unit would deny as there is no corresponding vaccine code billed
***Administration codes should be billed on one line with multiple units wherever possible to avoid duplicate denials. Some States require that modifiers be appended to the serum code (s) and/or the vaccine administration code(s). Please refer to the communication posted by your State Fee for Service Medicaid Plan for further details for modifier requirements of each State.
State Exceptions
Arizona The SL modifier must be appended to the vaccine administration code and the serum code. If the SL modifier is not appended, both the administration and serum codes will be denied.
Per State Regulations, the serum code should be billed with a $0.00 charge. California Per State Regulations-
* California requires the SL modifier be appended to the vaccine serum code. If the SL modifier is not appended, the serum code will not be counted and the corresponding administration code will be denied.
* California will only reimburse administration code 90471 for VFC related vaccines. Exception: serum code 90723 must be billed with admin code 90460.
* Code 90644 needs to be billed with an SK modifier or SK and SL but not SL alone
* Code 90734 needs to be billed with modifiers SK and SL for children 0 to 10 but only with the SL modifier for children 11 to 18 Florida The Florida Healthy Kids product does not participate in the VFC program. Hawaii Hawaii’s VFC program services members through age 20.
Kansas Kansas Medicaid claims submitted with modifier SL will be denied unless the federal government has announced a vaccine shortage through the VFC program.
Maryland Maryland requires the SE modifier to be appended to the vaccine serum code effective with dates of service as of 9/1/13. If the modifier is not appended with dates of service on or after 9/1/13, the serum code will be denied. Per State Regulation, Maryland pays on the serum code rather than the vaccine administration code. The administration code is not required to be on the claim.
Massachusetts Massachusetts Senior Care Options (SCO) Plan is for individuals who are 65 and over and they do not enroll any children. The VFC program does not apply to Massachusetts. Mississippi The EP modifier must be appended to the vaccine administration code and the serum code. If the EP modifier is not appended, both the administration and serum codes will be denied.
CPT 90715 may be billed without the EP modifier for pregnant patients under 19 years of age.
Missouri Missouri requires the SL modifier be appended to the vaccine serum code. If the SL modifier is not appended, the serum code will be denied. Per State Regulation, Missouri pays on the serum code rather than the vaccine administration code. The administration code is not required to be on the claim. Missouri CHIP members should not be excluded from VFC Nebraska Nebraska requires the SL modifier be appended to the vaccine serum code. If the SL modifier is not appended, the serum code will be denied. Per State Regulation, Nebraska pays on the serum code rather than the vaccine administration code. The administration code is not required to be on the claim.
Nebraska’s SCHIP product does not participate in the VFC program. New Jersey Medicaid members in New Jersey’s FamilyCare Plans B, C, and D are excluded from this policy.
New Mexico Administration code 90461 is covered for VFC related vaccines. New York New York requires the SL modifier be appended to the vaccine serum code. If the SL modifier is not appended, the serum code will not be counted and the corresponding administration code will be denied.
New York will only reimburse administration code 90460 for VFC related vaccines. Ohio The Ohio Department of Medicaid developed a uniform pediatric vaccine billing policy and practice that will be implemented in both Medicaid Fee for Service and all the Managed Care Plans (MCPs). Medicaid FFS- and MCP-contracted providers shall adhere to the following instructions when coding and submitting claims for pediatric vaccines administered to Medicaid recipients:
Use CPT code 90460 for the administration of vaccines administered under the federal vaccines for children (VFC) program. CPT code 90461 should not be used for the reporting of each vaccine toxoid component of a combination vaccine since as previously noted above ODM will pay providers for each separate vaccine administration. Additionally, vaccine administration codes 90471 through 90474 should not be used for the administration of vaccines covered under the federal VFC program (since ODM applies a $15.00 payment for each vaccine being administered).
Report CPT code 90460 on each claim along with each vaccine toxoid CPT code administered. 90460 should be reported on multiple detail lines to indicate the total number of administrations performed. Total number of detail lines reported must equal total number of VFC vaccine toxoid codes administered by the provider. Submit a charge of $0.00 with the toxoid code to Medicaid MCPs and fee-for-service in order for the claims payment system to accurately process these claims. Report the appropriate vaccine toxoid CPT code for the administration of combination vaccines.
Separate payment for either an office visit or well child visit will be allowed as long as the provider’s documentation supports that a separately identifiable visit was performed in addition to the administration of vaccines. Providers will need to append the visit code with modifier 25 to signify that a separately identifiable visit was provided.
