||Fact Sheet For Medicare Influenza/Pneumococcal Vaccination Benefits
Effective October, 2000
(Download File--MS Word 97, 39 KB, self-extracting zip file)
CPT codes and descriptions only are copyright 1998 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.
- Medicare Part B began paying for influenza virus vaccines on May 1, 1993.
- Medicare Part B began paying for pneumococcal vaccines (PPV) on July 1, 1981.
- Coverage of the vaccines and their administration is available only under Medicare Part B regardless of the setting in which they are furnished.
- Medicare beneficiaries who get the vaccines do not pay the usual coinsurance or deductible amounts. Medicare pays those amounts, along with an amount for the vaccine and the person who administers the shot.
- Influenza vaccines are typically administered once a year in the fall or winter.
- PPV vaccines are typically administered once in a lifetime to persons at high risk of pneumonia infection. Considered at risk are persons 65 years of age and older; immunocompetent adults who are at increased risk of pneumonia infection or its complications because of chronic illness (e.g., cardiovascular disease, pulmonary disease, diabetes mellitus, alcoholism, cirrhosis, or cerebrospinal fluid leaks), and individuals with compromised immune systems (e.g., splenic dysfunction or anatomic asplenia, Hodgkin's disease, lymphoma, multiple myeloma, chronic renal failure, HIV infection, nephrotic syndrome, sickle cell disease, or organ transplantation).
- Claims are paid for beneficiaries who are at high risk of pneumonia infection and have not received PPV within the last five years or are revaccinated because they are unsure of their vaccination status.
- Medicare no longer requires for either flu or PPV coverage purposes that the vaccines be ordered by a doctor of medicine or osteopathy. Therefore, the beneficiary may receive either of the vaccines upon request without a physician or osteopath's order. However, for PPV, the physician should still determine the person's age, health and vaccination status; and obtain a signed consent.
- The change in policy allowing for PPV to be given without a doctor's order is scheduled to be effective August 15, 2000 per Transmittal 1667 of the Medicare Carriers Manual, Transmittal 1797 of the Medicare Intermediary Manual and Program Memorandum Transmittal AB-00-58 for Intermediaries and Carriers. Providers should check with their carrier or FI to confirm that date on or after August 15.
- If a physician sees a beneficiary for the sole purpose of administering a flu or PPV vaccination, the physician may only bill for the administration and vaccine. However, if a patient actually receives reasonable and medically necessary services constituting an "office visit" level of service, the physician may bill for the office visit, the vaccine and the administration of the vaccine.
- Influenza virus vaccine is billed using diagnosis code V04.8.
- PPV is billed using diagnosis code V03.82.
- Influenza virus vaccine is billed using HCPCS codes 90657, 90658 or 90659. These codes are for the vaccines only and do not include administration. It is the responsibility of the provider/supplier to use the correct code based on the CPT description. The codes are not interchangeable.
- Administration of influenza virus vaccine is billed using HCPCS code G0008.
- PPV is billed using HCPCS code 90732. This code is for the vaccine only and does not include administration.
- Administration of PPV is billed using HCPCS code G0009.
- Providers other than independent rural health clinics (RHCs) and freestanding federally qualified health centers (FQHCs) bill for the vaccines and their administration on Form HCFA-1450 using revenue code 636 for the vaccine and 771 for the administration of the vaccine in conjunction with the diagnosis and HCPCS codes.
- Independent RHCs and freestanding FQHCs do not include charges for the vaccines or their administration on the HCFA-1450. They bill in accordance with Section 614 of the RHC/FQHC manual.
- Physicians, suppliers and hospices bill for the vaccines and their administration on Form HCFA-1500.
- There is no charge to the beneficiary if the provider administering the vaccines accepts the Medicare payment as payment in full, i.e., the provider "takes assignment."
- Medicare beneficiaries who get the vaccines from providers who do not accept assignment will be responsible for charges in excess of what Medicare pays.
Billing by Providers and Suppliers
- Limiting charge rules do not apply to the vaccines or administration services.
- For the purpose of influenza or PPV vaccination benefits, any individual or entity meeting State licensure requirements may qualify to bill Medicare for furnishing and administering the vaccines to Medicare beneficiaries enrolled under Part B.
- Provider facilities not participating in Medicare, e.g., nursing homes, are considered suppliers and bill their local carrier.
- The Part B carrier will provide the Form HCFA-855, the Provider/Supplier Enrollment application, to these facilities upon request.
- Providers such as public health clinics that have never submitted Medicare claims must obtain a provider number by contacting their Part B carrier for a Provider/Supplier Enrollment application.
- Entities such as drugstore chains which meet State requirements to furnish and administer influenza and PPV vaccinations may bill local carriers as suppliers.
- A self-employed nurse who is licensed under State law to administer influenza and PPV vaccinations may obtain a provider number and bill the local carrier for those vaccinations administered to Medicare beneficiaries.
- HMOs that furnish influenza or PPV vaccinations to nonmember Medicare beneficiaries are treated as suppliers and bill the carrier.
- To alleviate concerns expressed by some Public Health Clinics (PHCs) and other properly-licensed individuals and entities which bill Medicare sporadically, the Health Care Financing Administration (HCFA) initiated a roster billing process in 1993 for these entities that bill the carrier.
- Effective for services furnished on or after November 1, 1996, the roster billing process was expanded to include the PPV vaccination. Providers that bill carriers and intermediaries, with the exception of independent RHCs and free-standing FQHCs, may roster bill for the influenza and PPV vaccination.
- In response to provider's request to simplify and quicken the provider enrollment process, Medicare has developed simplified instruction for the Form HCFA-855, Provider/Supplier Enrollment application. This enrollment process currently applies only to entities that will (1) bill the carrier; (2) use roster bills; and (3) bill only for PPV and/or influenza vaccinations. The Part B carrier will provide the Form HCFA-855.
- To qualify for roster billing, PHCs and other properly-licensed individuals and entities may use the simplified process if they: (1) conduct mass immunization programs (at least 5 beneficiaries on the same day is required except as noted below); and (2) agree to accept assignment for flu and PPV vaccination claims when billing carriers.
- NOTE: The 5 immunizations per day requirement is waived for hospitals providing flu or PPV shots to their inpatients.
- Effective July 1, 1998, for provider/supplier claims submitted to carriers for payment, immunization of at least five beneficiaries on the same date is no longer required for any individual or entity to qualify for roster billing. However, the rosters should not be used for single patient bills and the date of service for each vaccination administered must be entered.
- Entities which submit claims on roster bills and therefore must accept assignment may not collect any "donation" or other cost-sharing of any kind from Medicare beneficiaries for influenza or PPV vaccinations. However, the entity may bill Medicare for the amount which is not subsidized from its own budget. For example, an entity that incurs a cost of $7.50 per vaccination and pays $2.50 of the cost from its budget may bill Medicare the $5.00 cost which is not paid out of its budget.
- Hospitals that roster bill the vaccines for their inpatients may report the actual date of service instead of the discharge date.
- For roster billing, carriers use Form HCFA-1500 and intermediaries use Form HCFA-1450 with preprinted standardized information relative to the provider/supplier.
- Mass immunizers attach a standard roster to a single pre-printed HCFA-1500 or HCFA-1450 which contains variable claims information necessary for processing each claim.
- A stamped signature on file is acceptable on a roster claim to qualify as an actual signature providing that the provider has a signed authorization on file to bill Medicare for services rendered.
- Providers/suppliers that do not mass immunize should continue to bill for influenza and PPV using the normal billing method, i.e., submission of a HCFA-1450, HCFA-1500 or electronic billing for each beneficiary.
- The following warning must be printed on the PPV roster bill form:
- WARNING: Ask beneficiaries if they have been vaccinated with PPV.
- Rely on patients memory to determine prior vaccination status.
- If patients are uncertain whether they have been vaccinated within the past 5 years, administer the vaccine.
- If patients are certain that they have been vaccinated within the past 5 years, do not re-vaccinate.
- For more information, mass immunizers should contact their local carrier or intermediary.
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Editor: Susan K. Boyer, RN
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