Today the Centers for Medicare and Medicaid Services (CMS) released the new pricing for flu shots for Medicare patients for the 2011-2012 flu season. The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95% of the Average Wholesale Price (AWP) as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department. When the vaccine is furnished in the hospital outpatient department, payment for the vaccine is based on reasonable cost.
What do Medicare patients have to pay for the flu shot?
Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations. All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine. Do not collect from Medicare patients for the vaccine or the administration of a flu shot.
What will Medicare pay for the flu shot?
The payment allowances below reflect the annually updated payment allowance for the listed CPT codes and Q-codes when the vaccines are furnished outside the hospital outpatient department.
Allowables Effective for Dates of Service between September 1, 2011 and August 31, 2012
CPT 90654: $18.383
CPT 90655: $15.705
CPT 90656: $12.375
CPT 90657: $6.653
CPT 90660: $22.316
CPT 90662: $30.923
Q2035 (Afluria): $11.543
Q2036 (Flulaval): locally priced
Q2037 (Fluvirin): $13.652
Q2038 (Fluzone): $13.306
Q2039 (N.O.S.): locally priced
How should the flu shot be coded?
- Choose the Q code or CPT code that is appropriate for the brand of vaccine you are giving or the special circumstances (pediatric dose, regular dose, high dose, preservative free, etc.)
- Use the Administration Code G0008
- Use the Diagnosis Code: V04.81
Choose one code for the vaccine:
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
90660 Influenza virus vaccine, live, for intranasal use
90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirun)
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 Influenza virus vaccine, split virus, when administered to individuals3 years of age and older, for intramuscular use (Not Otherwise Specified)
How many flu shots will Medicare pay for?
Medicare will pay for one flu shot per influenza season in the fall or winter. Medicare may cover additional seasonal influenza virus vaccinations if medically necessary.
What is different if the patient gets the flu shot somewhere besides the physician’s office?
Institutional Providers: Additional Billing Information
Hospitals, other than Indian Health Service (IHS) Hospitals
and Critical Access Hospitals (CAHs) 12X, 13X
CAHs: Method I and II and IHS CAHs 85X
IHS Hospitals 12X, 13X
Skilled Nursing Facilities (SNFs) 22X, 23X
Home Health Agencies (HHAs) 34X
Comprehensive Outpatient Rehabilitation Facilities (CORFs) 75X
Revenue Codes: 0636 vaccine
Rural Health Clinics (RHCs) 71X
Federally Qualified Health Centers (FQHCs) – 77X (for dates of service on or after April 1, 2010)
Do providers that only provide immunizations need to enroll in the Medicare Program?
Yes. Providers must enroll in the Medicare Program even if immunizations are the only service they will provide to beneficiaries. They should enroll as provider specialty type 73, Mass Immunization Roster Biller, by completing Form CMS-855I for individuals or Form CMS-855B for a group.
Click here to locate these forms.
What is a mass immunizer?
A mass immunizer offers seasonal influenza virus and/or pneumococcal vaccinations to a large number of individuals and may be a traditional Medicare provider or supplier or a nontraditional provider or supplier (such as a senior citizens center, a public health clinic, or a community pharmacy). Mass immunizers must submit claims for immunizations on roster bills and must take assignment on both the vaccine and its
administration. A mass immunizer should enroll with the Medicare Contractor prior to influenza season.
What is Roster Billing?
(Influenza & Pneumococcal Vaccinations Only)
The simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass PPV and influenza virus vaccination programs. (Medicare has not developed roster billing for hepatitis B or other vaccinations.) Roster billing can also substantially lessen the administrative burden on physician practices by allowing them to submit one claim for all of the Medicare beneficiaries that received either the PPV or influenza vaccine on a given day. Medicare will often refer to these providers, who utilize roster billing, as Mass Immunizers.
For Medicare Part B submission, physician practices and other Mass Immunizers must submit a separate pre-printed CMS-1500 paper claim form or bill electronically for each type of vaccination (either influenza or PPV) and attach a roster list containing information for 2 or more Medicare beneficiaries. When mass immunizers choose to conduct roster billing electronically, they are required to use the HIPAA-adopted ASC X12N 837 claim standard. Local Medicare Carriers may offer low or no-cost software to help providers utilize roster billing electronically, however, this software is not currently available nationwide so check with your local carrier for specifics in your area.
All entities that submit claims on roster bills must accept assignment.
Roster bills submitted by providers to a Medicare carrier must contain more than one patient and the date of service for each vaccination administered must be the same. (Medicare policy was changed July 1, 1998, and the requirement that a minimum of five beneficiaries be vaccinated per day in order to roster bill was reduced to two beneficiaries per day.)
To further minimize the administrative burden of roster billing, the following blocks can be preprinted on a CMS-1500:
Block 1: Medicare
Block 2: See Attached Roster
Block 11: None
Block 20: No
Block 21: V04.81 for influenza or V03.82 for pneumococcal
Block 24B: ALL entities should use POS code 60 for roster billing. (POS code 60 = Mass
Block 24D: Use appropriate vaccine and administration codes (separate line items for each)
Block 24E: Use 1 for lines 1 and 2
Block 24F: Use the unit cost of the particular vaccine (Contractors will replicate the claim for
each beneficiary listed on the roster.)
Block 27: Yes
Block 29: $0.00
Block 31: Signature
Block 32: Enter the name, address and zip code of the location where service was provided
Block 32a: NPI of the service facility
Block 33: Provider Identification Number or NPI when required
Block 33a: NPI of the billing provider or group
A separate CMS-1500 for each type of vaccination must have an attached roster that includes the
Patient Name and Address
Health Insurance Claim Number
Date of Birth
Date of Service
Providers Name and Identification Number
Signature or stamped Signature on File
Control number for the contractor
A signature on file stamp or notation qualifies as a signature on a roster claim form in cases where the provider has access to a signature on file in the beneficiarys record (e.g., when the vaccine is administered in a physicians office).
The format of the beneficiary roster can be modified to meet the needs of individual providers. It is the responsibility of the carrier to develop suitable roster formats that meet provider and carrier needs and contain the minimum data necessary to satisfy claims processing requirements for these claims.