CPT 90658, 90656 and G0008

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.

Since Medicare reimbursement rates change periodically, providers are encouraged to enroll in a relevant CMS electronic mailing list at http://www.cms.gov/ AboutWebsite/20_EmailUpdates.asp for the latest updates.




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

Overview

Influenza, pneumococcal infections, and hepatitis B are vaccine-preventable diseases that cause substantial illness and premature death in the United States each year. During an average influenza season, nearly 5 to 20 percent of the population may contract the virus. About 41,000 Americans die each year from influenza and pneumonia, the 8th leading cause of death in the United States. The hepatitis B virus causes significant morbidity and mortality worldwide. According to the Centers for Disease Control and Prevention (CDC), an estimated 1.25 million Americans are chronically infected with hepatitis B. In the United States, chronic hepatitis B virus infection is responsible for about 5,000 annual deaths from cirrhosis of the liver and liver cancer. The Medicare Program provides coverage for the influenza, pneumococcal, and hepatitis B vaccinations and their administration. These vaccines are safe, effective, and can help reduce disease incident, morbidity, and mortality, and ultimately reduce health care costs.

Influenza (Flu) Virus Vaccine


Influenza, also known as the flu, is a contagious disease that is caused by influenza viruses and generally occurs during the winter months. It attacks the respiratory tract in humans (nose, throat, and lungs). Influenza is a serious illness that can lead to pneumonia. The risks for complications, hospitalizations, and deaths from influenza are higher among individuals aged 65 years and older, young children, and persons of any age with certain underlying health conditions than among healthy older children and younger adults. An annual influenza vaccination is still the best way to prevent influenza and its severe complications.

Coverage Information

Coverage of the influenza virus vaccine and its administration was added to the Medicare Program on May 1, 1993. Medicare provides coverage for one influenza virus vaccine per flu season for all beneficiaries. This may mean that a beneficiary will receive more than one influenza vaccination in a 12-month period. Medicare may provide coverage for more than one influenza vaccination per flu season if it is reasonable and medically necessary.


CPT and payable Diagnosis (DX)


90655 - Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use

90656 -  Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use

90657 -  Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use

90658 -  Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use

90660 -  Influenza virus vaccine, live, for intranasal use

G0008 - Administration of influenza virus vaccine


CPT CODE 90658 Replaced by

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)

Diagnosis Requirements

When a Medicare provider files a claim, they must report the appropriate diagnosis code. If the sole purpose for the visit was to receive the influenza virus vaccine or if the influenza virus vaccine is the only service billed on a claim, the provider must report diagnosis code V04.81.

However, if the purpose of the visit was to receive both the influenza virus vaccine and the pneumococcal vaccine,Medicare providers must report diagnosis code V06.6.

Reasons for Claim Denial

An example of a situation where Medicare may deny coverage of influenza virus vaccination is when a beneficiary requests more than one influenza virus vaccination during the same influenza season and the Medicare provider cannot justify the medical necessity of the second vaccination.

Provider Action Needed

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.

Box 21: Diagnosis: Influenza - V04.81 Pneumococcal - V03.82 Influenza and Pneumococcal - V06.6


You now have five new HCPCS Level II codes to report to Medicare during the 2010-2011 influenza season, and reimbursement is going up for some immunizations. New Q codes repay CPT® code 90658, which describes the regular adult dose vaccine that is supplied in a multi-dose vial. The change was necessary, according to the Centers for Medicare & Medicaid Services (CMS), to renew separate billing digest for each brand name vaccine product inclosed in 90658.


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.


CPT CODE 90656 (4 yrs & older) Guide



Once per influenza season Medicare may cover additional seasonal influenza virus vaccinations if medically necessary

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
authorization.

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
90658 HA Influenza virus vaccine, intramuscular $18.12
90686 HA Influenza virus vaccine, intramuscular, preservative free $25.38
90732 HA Pneumococcal polysaccharide vaccine, 23-valent, subcutaneous or intramuscular $67.19



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
90686 Influenza virus vaccine, intramuscular, no preservative free $18.16
90732 Pneumococcal polysaccharide vaccine, 23-valent, subcutaneous or intramuscular adult or immunosuppressed patient dosage $82.51


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
2. Enter quantity in milliliters
3. Day supply must be less than 30
4. Enter “MA” in the Professional Service field
5. Enter an administration fee >$0.01 and < $15.01


Billing Guide for CPT CODE G0008


Seasonal Influenza Virus Vaccine Administration Code: G0008 Diagnosis Code: Z23


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?

Yes, see  https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html for individual Change Requests (CRs) and coding translations for ICD-10. Use separate administration codes for the seasonal influenza virus (G0008) and pneumococcal (G0009) vaccines. Medicare pays both administration fees if a beneficiary gets both the seasonal influenza virus and the pneumococcal vaccines on the same day .

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 
- 3 - © ACP 2015 (FQHC). Where the vaccine is furnished in the hospital outpatient department, RHC, or FQHC, payment for the vaccine is based on reasonable cost. 

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. 

However, if a provider utilizes “roster billing,” (see next page), additional services should not be listed on the roster bill. All other covered services, including office visits, are subject to more comprehensive data requirements and should be billed using normal Part B claims filing procedures and forms. 


 Separate Claims for Vaccine and Their Administration 

In situations in which the vaccine and the administration are furnished by two different entities, the entities should submit separate claims.  For example, a supplier (e.g., a pharmacist) may bill separately for the vaccine, using the Healthcare Common Procedural Coding System (HCPCS) code for the vaccine, and the physician or supplier (e.g., a drugstore) who actually administers the vaccine may bill separately for the administration, using the HCPCS code for the administration.  This procedure results in contractors receiving two claims, one for the vaccine and one for its administration. 

For example, when billing for influenza virus vaccine administration only, billers should list only HCPCS code G0008 in block 24D of the Form CMS-1500.  When billing for the influenza virus vaccine only, billers should list only HCPCS code 90658 in block 24D of  the Form CMS-1500.  The same applies for pneumococcal and hepatitis B billing using pneumococcal and hepatitis B HCPCS codes. 

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