Billing for Influenza: New CPT Code 90674
The American Medical Association issued a new Current Procedural Terminology (CPT) code for influenza vaccine Flucelvax, CPT 90674, effective August 1, 2016 for Medicare claims. However, Medicare claims processing systems will not be able to accept the new code until January 1, 2017. Until this time, you may hold claims containing CPT 90674. Finally, if you bill institutional claims, note that code CPT 90674 will be implemented on February 20, 2017.
Influenza/Pneumonia Vaccines for Medicare Advantage (HMO) Patients
It is that time of year again when many private and public health entities are offering influenza and pneumococcal vaccines in their offices or conducting mass immunization clinics.
Palmetto GBA promotes the use of roster billing to providers who do mass immunizations. It is very important with the growing population of Medicare patients electing to join Medicare Advantage (MA) plans that you verify each patient's enrollment in Medicare, whether the person is enrolled in 'traditional' fee-for-service Medicare or an MA plan. We strongly recommend that you question the patient prior to the administration of the vaccine to identify the responsible Medicare plan. Only submit claims to Palmetto GBA for patients that have traditional Medicare. Claims submitted for beneficiaries that are enrolled in an MA plan will be rejected as billing errors.
For patients that are enrolled in MA plans:
We encourage you to check with the patient's MA plan for plan-specific billing guidelines prior to administering flu or pneumonia vaccines
Medicare patients enrolled in MA plans generally must obtain their vaccines through plan providers or they will have to pay for it out-of-pocket
MA enrollees should check with their plan to determine if they are locked in to plan providers for their flu and pneumococcal vaccines. If they are locked in, they may obtain the vaccines from any qualified provider. However, the provider must submit claims to the MA plan and not to Palmetto GBA.
Resources for MA Plans:
CMS resources external link for provider that administer influenza and pneumococcal vaccines
To locate information regarding MA plans, please visit the CMS website external link to view the 'Medicare Managed Care Manual and Plan Directory'
Billing Update from UHC insurance
Implementation Date: January 3, 2017
Change Request (CR) 9793 which informs MACs about the changes to instructions for payment and edits for the Common Working File (CWF) to include influenza virus vaccine code 90674 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use) as payable for claims with dates of service on or after August 1, 2016, processed on or after January 3, 2017. Make sure that your billing st
affs are aware of these changes.
CR9793 provides instructions for payment and edits to include influenza virus vaccine code 90674. Medicare waives coinsurance and deductibles for code 90674. Medicare will pay for code 90674 based on reasonable cost when submitted by:
Hospitals on Type of Bill (TOB) 12X and 13X
Skilled Nursing Facilities on TOB 22X and 23X
Home Health Agencies on TOB 34X
Hospital-Based Renal Dialysis facilities on 72X, and
Critical Access Hospitals (CAHs) on TOB 85X
MACs will pay for influenza virus vaccine code 90674 based on the lower of the actual charge or 95 percent of the Average Wholesale Price (AWP) to:
Indian Health Services (IHS) hospitals submitting claims on TOB 12X and 13X
IHS CAHs submitting claims on TOB 85X
Comprehensive Outpatient Rehabilitation Facilities using TOB 75X, and
Independent Renal Dialysis Facilities using TOB 72X
It is important to note that MACs will hold institutional claims with code 90674 with dates of service on or after January 1, 2017, through February 20, 2017, until the Fiscal Intermediary Shared System (FISS) changes are implemented on February 20, 2017. Medicare will issue further instructions on how to handle claims for code 90674 with dates of service from August 1, 2017, through December 31, 2016
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