CMS Releases Pricing and Codes for 2011 – 2012 Flu Vaccine Given After September 1, 2011

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NOTE: The 2012 – 2013 flu shot codes can be found here.

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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?

  1. 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.)
  2. Use the Administration Code G0008
  3. 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
0771 – administration

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
Immunization Center.)

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
following information:
• Patient Name and Address
• Health Insurance Claim Number
• Date of Birth
• Sex
• Date of Service
• Provider’s 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 beneficiary’s record (e.g., when the vaccine is administered in a physician’s 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.

Posted in: Day-to-Day Operations, Medicare & Reimbursement

Leave a Comment (45) ↓

44 Comments

  1. darlene wheeler September 20, 2011

    what is the valid CPT code for a flu shot that is non-split for 3yrs plus and not medicare? thanks

    • Mary Pat Whaley September 20, 2011

      Hi Darlene,

      I found some conflicting information online about whether whole virus influenza vaccines are currently available in the US, so I struck out on trying to find a code for you. Maybe another reader has the answer for you. Readers?

      Best wishes,

      Mary Pat

  2. D. PEDRETTI September 21, 2011

    Is a modifier necessary when billing fluvirin?

    • Mary Pat Whaley September 24, 2011

      I am not aware of any modifiers needed for fluvirin, unless it is related to a state vaccine program. Do any readers know of needed modifiers?

      Best wishes,

      Mary Pat

  3. J. Campbell September 28, 2011

    We’re giving the high dose to most of our 65+ patients. There is no Q code for this – just the 90662? Thanks.

    • Mary Pat Whaley October 3, 2011

      That’s the way I read the Medicare guidelines.

      Best wishes,

      Mary Pat

  4. Amy October 10, 2011

    I work for an Endocrinologist in NYC. I’m his OM and Biller. It’s hard to keep up w/all the changes. He is also licensed as an Internist and has a small, basic clinical lab in the back. I bill most codes w/the Medicare required QW separately as the regulation states, for the Medicare patients he does NOT Accept assignment on. My confusion is…do I need a modifier 25 for the flu shot because it is a separate procedure from the patient’s follow-up Diabetic visits. Do I bill it with the clincial lab codes OR with the E/M codes? PLEASE ADVISE. It is much appreciated.

    • Mary Pat Whaley October 16, 2011

      Hi Amy,

      You are not alone – it is very hard for all of us to keep up with the changes!
      Modifier 25 is applied to the visit (E&M) code only when it is separate and distinct from a procedure or a preventive code. It is meant to keep the payer from denying the code based on the bundling rule, where procedures are supposed to include everything that happens at that visit.
      You can use your lab codes and your flu shot codes in conjunction with the E&M as long as you have the supporting ICD-9 to show medical necessity.
      So, if you have an established patient come in for a diabetes check and some labs are done for the diabetes and a flu shot is given, you would use the correct level of E&M, the lab codes and the flu shot codes with no modifer 25, and you would use the diabetes diagnosis for the visit and labs and the recommended diagnosis for the flu shot.

      Best wishes,

      Mary Pat

  5. Jan Allen October 11, 2011

    I found this site while googling trying to get info re: Non-Medicare pt. flu vac. cpt billing codes for 2011. On another site it says to still bill with 90657 for 3-35months, & 90658 for 3yrs and over. It seems only Medicare wants to know which of the flu vac brands you’re giving in your office by having the new Q codes for billing. When we’re trying to build picklists for our Electronic Health Record system, it sure makes it confusing and time consuming for the nurses/Drs. to have to check the pt’s ins. first on every pt they see before making a picklist selection for a charge, and if they pick the wrong one, the biller/coder has to re-work the claim before it can be submitted…

    • Mary Pat Whaley October 16, 2011

      Hi Jan,

      As always, when you have to use one set of codes for Medicare and one set for everyone else, everything becomes more confusing. The best situation is when you can enter the type of flu shot, and the EMR/PM does the work of picking the code based on the insurance on file for the patient. Your system should be able to do this for you behind the scenes if you take the time to set it up that way. Ask your vendor!

      Best wishes,

      Mary Pat

  6. Sharon Evans October 25, 2011

    Can you tell me if a home health agency can bill for flu shot. And is it billed on UB04. We don’t have a physician on staff so we don’t bill 1500’s. Can you please help.

    • Mary Pat Whaley November 2, 2011

      Hi Sharon,

      I have been looking for the answer to your question and I just became aware of this comprehensive Q&A on flu shots from CMS – hopefully this will have your answer: 2011-2012 Immunizers’ Question & Answer Guide to Medicare Part B and Medicaid Coverage of Seasonal Influenza and Pneumococcal Vaccinations available at http://www.cms.gov/Immunizations/Downloads/20112012ImmunizersGuide.pdf on the CMS website.

      Best wishes,

      Mary Pat

  7. Lynn Alley November 1, 2011

    I do flu shot billing for home health in TN. We do not have access to submit 1500 forms electronically and do not always meet the criteria for Roster billing (sometimes only 1 flu shot on a specific date). Is there another way to bill flu shots; especially since there is a problem with entering roster claims due to not all info required on a claim can be entered on a roster claim? Thanks so much for your assistance.

    • Mary Pat Whaley November 2, 2011

      Hi Lynn,

      I just became aware of this comprehensive Q&A on flu shots from CMS – hopefully this will have your answer: 2011-2012 Immunizers’ Question & Answer Guide to Medicare Part B and Medicaid Coverage of Seasonal Influenza and Pneumococcal Vaccinations available at http://www.cms.gov/Immunizations/Downloads/20112012ImmunizersGuide.pdf on the CMS website.

      Best wishes,

      Mary Pat

  8. pat schmidt November 14, 2011

    I’m trying to find out how much medicare will reimburse for the administrative fee for the flu vaccine. Unable to find a website with specific reimbursement dollar amount.Thank you

    • Mary Pat Whaley November 16, 2011

      Hi Pat,

      I’ve not seen anything about the reimbursement for the administration of the vaccine. I am thinking it was around $12 in 2009-2010.

      Can anyone else chime in?

      Best wishes,

      Mary Pat

  9. Fay Lee November 16, 2011

    New to billing. do we charge for the vaccine 90656 and the administration G0008 or 90471 Our software want to have a charge for the administration has to have a number greater than zero

    • Mary Pat Whaley November 16, 2011

      Hi Fay,

      Yes, you charge for the administration and the vaccine itself. In the past, many practices have priced the total package (vaccine and administration) at around $25 to compete with the local pharmacies.

      Best wishes,

      Mary Pat

  10. Melanie November 17, 2011

    Do you know if Medicare Advantage plans (Humana Gold) require the Medicare Q code for flu shots or the “everybody else” code?

    • Mary Pat Whaley November 22, 2011

      Hi Melanie,

      Yes, they do.

      Best wishes,

      Mary Pat

  11. Kim Needles November 22, 2011

    Can hospitals bill for flu shots? And what code shall we use?

    • Mary Pat Whaley November 22, 2011

      Hi Kim,

      Everything I know about hospitals giving flu shots is in that post, Kim, but maybe a reader can add to the information. Does anyone have more to add?

      Best wishes,

      Mary Pat

  12. Susan O'Connor February 7, 2012

    Mary Pat,
    We are Non-Par with Medicare. I know we have to take assignment on the flu vaccine but can we not collect the admin fee from the patient? Do we have to take assignment on both drug and admin? Thank you.
    Susan

    • Mary Pat Whaley February 12, 2012

      Hi Susan,

      This is a great question!

      The “Immunizers Guides to Flu and PPV Vaccinations” published by CMS had this Q & A:

      C.9 May providers, physicians, and suppliers charge and collect payment from Medicare beneficiaries for the influenza virus or pneumococcal vaccinations?

      Non-participating physicians, providers and suppliers that do not accept assignment on the administration of the vaccines may collect payment from the beneficiary, but they must submit an unassigned claim on the beneficiary’s behalf. All physicians, non-physician practitioners and suppliers must accept assignment for the Medicare vaccine payment rate and may not collect payment from the beneficiary for the vaccine.

      Participating physicians, non-physician practitioners and suppliers that accept assignment must bill Medicare if they charge a fee to cover any or all costs related to the provision and/or administration of the influenza virus or pneumococcal vaccine. They may not collect payment from beneficiaries.

      Best wishes!

      Mary Pat

  13. Jennifer Holder February 16, 2012

    Can anyone help with billing Medicare for flu vaccine with required NDC Drug code. MDCR is asking for price, units ect. I include on my claims but still rejecting

    • Mary Pat Whaley February 27, 2012

      Hi Jennifer,

      Try this tip I found on Manny Oliverez’s (http://bit.ly/yV6BvC) site:

      There is a specific format that you must follow when you put it into your computer system. NDCs are in a 11-digit format and are usually seen in a 5-4-2 format. For example: 99999-9999-99. Sometimes, just to confuse things I believe, they are in 10-digit formats. Before entering the number into your computer system you must convert it to an 11-digit NDC.

      Use the following methodology to convert your NDCs from 10-digits to 11-digits:

      If 10-digit NDC format is: 4-4-2 9999-9999-99
      Then add a zero (0) in: 1st position 09999-9999-99
      Report NDC as: 09999999999

      If 10-digit NDC format is: 5-3-2 99999-999-99
      Then add a zero (0) in: 6th position 99999-0999-99
      Report NDC as: 99999099999

      If 10-digit NDC format is: 5-4-1 99999-9999-9
      Then add a zero (0) in: 10th position 99999-9999-09
      Report NDC as: 99999999909

      If it works, be sure to thank Manny!

      Best wishes,

      Mary Pat

  14. Jaime March 21, 2012

    If a flu vaccine is administered at a pharmacy vs. administered at a physicians office, how are claims billed? A physicians office would use the CPT code for the vaccine and a CPT code for the administration (example, Q2038 & G0008) and the claim would be processed through the medical policy as preventive. Since pharmacies bill Part D with NDC codes, not CPT codes, how would the flu vaccine and administration be processed and paid for? Is the reimbursement bundled into the rate for the vaccine?

    • Mary Pat Whaley March 21, 2012

      Hi Jaime,

      I don’t know how pharmacies bill, but I would not be surprised if they roster bill Part B for flu shots.

      Does anyone else know?

      Thanks for the question.

      Best wishes,

      Mary Pat

  15. SueAnn March 21, 2012

    Pharmacies will bill depending on the insurance / PBM plan. We do roster billing, CPT / HCPCS code billing, and by NDC. Med B is roster bill but when the patient has Med D Advantage it is eitheer CPT/HCPCs or NDC. Some of the claims are sent as a bundle and some are seperated out by vaccine and administration. Hope these gives you a clear answer to the “muddy” picture.

    • Mary Pat Whaley March 21, 2012

      Thanks for the feedback, SueAnn!

      Best wishes,

      Mary Pat

  16. Jaime April 3, 2012

    Hi Mary Pat,

    Thank you so much for your input. Also, to Sue Ann, when claims are sent to the PBM/insurance, are both the vaccine and the administration covered, and if so are they reimbursed separately (ex Q2038 $13.31 G0008 $27.54-Manhattan)? I appreciate your advice and thanks again for your information!

    Jaime

  17. glennys July 3, 2012

    Hello, I was hoping someone can help me on the following: CPTs 90471 and 90715 performed have denied as routine services are not covered by Medicare due to primary DX (V06.1); please advise of a more appropriate diagnosis (non-V) for re-submission of CPT 90471 .Thank you

    • Mary Pat Whaley July 6, 2012

      Hi Glennys,

      Your Medicare Administrative Carrier should have the answer to this, but on one MAC’s site I found:

      The treatment for whooping cough is not an approved preventive component by Medicare, therefore the entire toxoid/vaccine will deny as non-covered. Claim submissions for CPT 90715 will auto-deny and will appear on a remittance advice with a patient responsibility (PR-96), “Non-covered charge(s),” denial message.

      I hope this helps.

      Best wishes,

      Mary Pat

      Posted: 4/5/2012

  18. Jan C August 3, 2012

    Has anyone received information of the coding of the flu vaccine for the upcoming season – 2012-2013? I am interested in Medicare and private insurance. Thank you.

    • Mary Pat Whaley August 7, 2012

      Hi Jan,

      We’ll be writing about this in the next week or so.

      Best wishes,

      Mary Pat

  19. Pam August 20, 2012

    Is an ABN required for a flu and/or pnuemo vaccine?

    • Mary Pat Whaley August 20, 2012

      Hi Pam,

      Medicare covers both the seasonal flu shot and the once-in-a-lifetime pneumo vaccine, so no ABN is needed.

      Best wishes,

      Mary Pat

  20. Cynthia Robinson August 31, 2012

    Does Medicare have a “Q” code for Fluarix by GlaxoSmithKline? or do we use the NOS “G” code?

    Thank you,
    Cynthia

    • Mary Pat Whaley August 31, 2012

      Hi Cynthia,

      The only new Medicare code for 2012-2013 is Q2034 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Agriflu).

      Best wishes,

      Mary Pat

    • Mary Pat Whaley September 20, 2012

      Hi Cynthia,

      In further response to your question of 8/31, I did find out that practices giving FLUARIX (preservative free) to Medicare patients should be using 90656 and not the NOS code of Q2039.

      Best wishes,

      Mary Pat

  21. marianne duncan September 7, 2012

    where can I find a printable Mass Roster billing to use at my clinic for flu and pneumonia shots?

    • Mary Pat Whaley September 12, 2012

      Hi Marianne,

      Here is a good one in this packet from the American College of Physicians that you can download, print and duplicate: http://www.acponline.org/pmc/billvaccines.pdf.

      Best wishes,

      Mary Pat

  22. Tina October 9, 2012

    I wanted to confirm Admin code G0008 and appropiate for brand of vaccine Q2039 or Q2038 along with dx code v04.81 for billing purposes for medicare. I noticed last year we used 90658/90724 no reimbursement was given.
    Thanks!

    • Mary Pat Whaley October 12, 2012

      Hi Tina,

      The article you commented on was last year’s flu shot directions. This year’s codes and reimbursement are here: http://managemypractice.com/q2034-and-the-new-2012-2013-flu-shot-medicare-reimbursement-codes/

      For Medicare patients, you are correct to use the administration code G0008 and diagnosis V04.81, and choose the Q code OR 9xxxx code that relates to the specific brand/type of vaccine that your clinic is giving.

      Best wishes,

      Mary Pat