Procedure CODE 90764 - influenza virus vaccine

Implementation of New Influenza Virus Vaccine Code 

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

cpt code 90674 - UHC update

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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