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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


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Immunizations

Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule. (See items A, B, and C below.) In cases where a vaccination or inoculation is excluded from coverage, related charges are also not covered.

Pneumococcal Pneumonia Vaccinations

An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccination under Medicare Part B. A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered).

Those administering the vaccine should not require the patient to present an immunization record prior to administering the pneumococcal vaccine, nor should they feel compelled to review the patient’s complete medical record if it is not available. Instead, provided that the patient is competent, it is acceptable to rely on the patient’s verbal history to determine prior vaccination status.

Medicare does not require for coverage purposes that a doctor of medicine or osteopathy order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision.

Hepatitis B Vaccine

Part B provides coverage for hepatitis B vaccine and its administration, furnished to a

Medicare beneficiary who is at high or intermediate risk of contracting hepatitis B.

High-risk groups currently identified include (see exception below):

    • ESRD patients;
    • Hemophiliacs who receive Factor VIII or IX concentrates;
    • Clients of institutions for the mentally retarded;
    • Persons who live in the same household as a Hepatitis B Virus (HBV) carrier;
    • Homosexual men;
    •  Illicit injectable drug abusers; and
    • Persons diagnosed with diabetes mellitus.

Intermediate risk groups currently identified include:

    • Staff in institutions for the mentally retarded; and
    • Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work.

EXCEPTION: Persons in both of the above-listed groups in paragraph B, would not be considered at high or intermediate risk of contracting hepatitis B, however, if there were laboratory evidence positive for antibodies to hepatitis B. (ESRD patients are routinely tested for hepatitis B antibodies as part of their continuing monitoring and therapy.)

For Medicare program purposes, the vaccine may be administered upon the order of a doctor of medicine or osteopathy, by a doctor of medicine or osteopathy, or by home health agencies, skilled nursing facilities, ESRD facilities, hospital outpatient departments, and persons recognized under the incident to physicians’ services provision of law.

A charge separate from the ESRD composite rate will be recognized and paid for administration of the vaccine to ESRD patients.

Influenza Virus Vaccine

Medicare Part B covers influenza virus vaccine and its administration when furnished in compliance with any applicable State law by any provider of services or any entity or individual with a supplier number. Typically, these vaccines are administered once a flu season. Medicare does not require, for coverage purposes, that a doctor of medicine or osteopathy order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision.

Coverage Requirements

Pneumococcal vaccine, influenza virus vaccine, and hepatitis B vaccine and their administration are covered only under Medicare Part B, regardless of the setting in which they are furnished, even when provided to an inpatient during a hospital stay covered under Part A.

Pneumococcal Vaccine

Medicare does not require for coverage purposes, that a doctor of medicine or osteopathy order the pneumococcal vaccine and its administration. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision.

Influenza Virus Vaccine

The influenza virus vaccine and its administration is covered when furnished in compliance with any applicable State law. Typically, this vaccine is administered once a flu season. Medicare does not require for coverage purposes that a doctor of medicine or osteopathy order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision. Since there is no yearly limit, A/B MACs (A) and (B) determine whether such services are reasonable and allow payment if appropriate.

Hepatitis B Vaccine

The hepatitis B vaccine and its administration is covered if it is ordered by a doctor of medicine or osteopathy and is available to Medicare beneficiaries who are at high or intermediate risk of contracting hepatitis B, e.g., exposed to hepatitis B.

Billing Requirements

Edits Not Applicable to Pneumococcal or Influenza Virus Vaccine Bills and Their Administration

The Common Working File (CWF) and shared systems bypass all Medicare Secondary Payer (MSP) utilization edits in CWF on all claims when the only service provided is pneumococcal or influenza virus vaccine and/or their administration. This waiver does not apply when other services (e.g., office visits) are billed on the same claim as pneumococcal or influenza virus vaccinations. If the provider knows or has reason to believe that a particular group health plan covers pneumococcal or influenza virus vaccine and their administration, and all other MSP requirements for the Medicare beneficiary are met, the primary payer must be billed.

First claim development alerts from CWF are not generated for pneumococcal or influenza virus vaccines. However, first claim development is performed if other services are submitted along with pneumococcal or influenza virus vaccines.

Institutional Claims

The following “providers of services” may administer and submit institutional claims to the MACs for these vaccines:

    • Hospitals;
    • Critical Access Hospitals (CAHs);
    • Skilled Nursing Facilities (SNFs);
    • Home Health Agencies (HHAs);
    • Hospices;
    •  Comprehensive Outpatient Rehabilitation Facilities (CORFs); and
    • Indian Health Service (IHS)/Tribally owned and/or operated hospitals and hospital-based facilities.

Other billing entities that may submit institutional claims are:

    • Independent Renal Dialysis Facilities (RDFs).

All providers submit institutional claims for hepatitis B. Providers other than independent RHCs and freestanding FQHCs submit institutional claims for influenza virus and pneumococcal vaccinations. (See §10.2.2.2 of this chapter for special instructions for independent RHCs and freestanding FQHCs.)

Institutional providers, other than independent RHCs and freestanding FQHCs, should bill for the vaccines and their administration on the same bill. Separate bills for vaccines and their administration are not required. The only exceptions to this rule occur when the vaccine is administered during the course of an otherwise covered home health visit since the vaccine or its administration is not included in the visit charge. (See §10.2.3 of this chapter).

Professional Claims

Billing for Additional Services

If a physician sees a beneficiary for the sole purpose of administering the influenza virus vaccine, the pneumococcal vaccine, and/or the hepatitis B vaccine, they may not routinely bill for an office visit. However, if the beneficiary actually receives other services constituting an “office visit” level of service, the physician may bill for a visit in addition to the vaccines and their administration, and Medicare will pay for the visit in addition to the vaccines and their administration if it is reasonable and medically necessary.

Nonparticipating Physicians and Suppliers

Nonparticipating physicians and suppliers (including local health facilities) that do not accept assignment may collect payment from the beneficiary for the administration of the vaccines, but must submit an unassigned claim on the beneficiary’s behalf. Effective for claims with dates of service on or after February 1, 2001, per §114 of the Benefits Improvement and Protection Act of 2000, all drugs and biologicals must be paid based on mandatory assignment. Therefore, regardless of whether the physician and supplier usually accept assignment, they must accept assignment for the vaccines, may not collect any fee up front, and must submit the claim for the beneficiary.

Entities, such as local health facilities, that have never submitted Medicare claims must obtain a National Provider Identifier (NPI) for Part B billing purposes.

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 Procedure 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.

Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Codes

HCPCS

Definition

90630

Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative

free, for intradermal use

90653

Influenza virus vaccine, inactivated, subunit, adjuvanted, for

intramuscular use

90654

Influenza virus vaccine, split virus, preservative-free, for intradermal use, for adults ages 18 – 64

90655

Influenza virus vaccine, split virus, preservative free, for children 6-

35 months of age, for intramuscular use

90656

Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use

90657

Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use

90658

Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use

90660

Influenza virus vaccine, live, for intranasal use

90661

Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use

90662

Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

90670

Pneumococcal conjugate vaccine, 13 valent, for intramuscular use

90672

Influenza virus vaccine, live, quadrivalent, for intranasal use

90673

Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use

90674

Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use

90682

Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use

90685

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

90686

Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use

90687

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

90688

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

90732

Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for us in individuals 2 years or older, for subcutaneous or intramuscular use

90739

Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use

90740

Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3

dose schedule), for intramuscular use

90743

Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use

90744

Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use

90746

Hepatitis B vaccine, adult dosage, for intramuscular use

90747

Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use

90756

Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use



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