Providing and Billing for the Flu Vaccine: Guidance from CMS, the CDC and the Affordable Care Act

Update posted 8-14-2012: For flu shot updates for the 2012-2013 influenza season, click here.

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Update posted 9-22-2011: For flu shot updates for the 2011-2012 influenza season, click here.

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Update Posted 12-20-2010 – Medicare posted code changes for flu vaccines billed to Medicare after January 1, 2011.  Click here for the changes.

For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.

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It’s that time again, and despite delayed deliveries to some hospitals and practices, the word on the street is that there will be enough flu vaccine (171 million doses) this year for all who want a flu shot.

Model of Influenza Virus from NIH

Image via Wikipedia

The Center for Disease Control (CDC) recommends that everyone 6 months and older get a flu shot.  Each year’s flu vaccine cocktail is unique and this season’s (2010-2011) flu vaccine will protect against three different flu viruses: an H3N2 virus, an influenza B virus and the H1N1 virus that caused so much illness last season.

The Affordable Care Act and the Influenza Vaccine

Just in time for flu season is the Affordable Care Act’s emphasis on preventive care.  The ACA states:

This influenza season, children 6 months through 18 years, certain high-risk adults 19 through 49 years, and adults 50 years and older who are enrolled in new group and individual health plans will be eligible to receive the seasonal flu vaccine without cost-sharing when provided by an in-network provider.  Beginning in the plan year that starts after March 2, 2011, all adults 19-49 years of age will be eligible to receive the seasonal flu vaccine with no cost-sharing requirements when provided by an in-network provider.

This is great news for the patient and for healthcare in general.  You may consider it good news or bad news, depending on your view of the whole flu shot process.  Here’s how it works in many practices:

  1. The vaccine is ordered in the spring, with everyone trying hard to guess correctly how many patients will want flu shots in 6 months.
  2. The vaccine arrives in the fall and the first hurdle is pricing it, as you will have to decide how much to mark it up to cover the cost of the ordering, handling and stocking and possibly a teeny profit.
  3. The administration of the vaccine also has to be priced to cover the cost of supplies (syringe, alcohol swab, sometimes a bandaid, printed Vaccine Administration Sheets) and the cost of labor (assessing the patient to make sure they can get the flu shot, giving the shot, and documenting the lot numbers in case of a recall.)
  4. The next decision is disbursement.  Do you have a flu shot clinic and have people get in line for the flu shot, or do you take flu shot appointments, do you give flu shots during regular appointments, or some combination thereof? What about drive-through flu clinics?  Do people sit in the parking lot for 15 minutes to make sure there are no bad after-effects?  How do you let patients know about your flu shot plans without costly postcards or advertisements?
  5. Then, there is policy setting for patients whose insurance covers the flu shot and for patients whose insurance does not.  Do you collect and refund if necessary, or do you not collect and bill the patient after insurance responds (Jaws theme music here, please.)

Does Medicare pay for flu shots?

Medicare pays 100% of the allowable for influenza vaccine (and pneumococcal vaccines) and the administration of the vaccines without any out-of-pocket costs to the patient.  One flu vaccine is allowable per flu season, but Medicare will pay for a second flu shot if a physician determines and documents the medical necessity.  A physician’s order is not necessary and a physician’s supervision is not necessary – that’s why patients are able to get a flu shot at the drugstore.  A patient can receive a flu shot twice in one calendar year by getting a flu shot late in one season and getting a flu shot early in the next season.

How should a provider that is not enrolled in Medicare bill for the flu vaccine?

CMS typically does not allow non-enrolled providers to treat Medicare beneficiaries, however, CMS is allowing them to give flu shots this year.  Beneficiaries can receive a flu vaccine from any licensed physician or provider. However, the billing procedure will vary depending on whether the physician or provider is enrolled in the Medicare Program.

If you are not a Medicare-enrolled physician or provider who gives a flu vaccine to a Medicare beneficiary, you can ask the beneficiary for payment at the time of service. The beneficiary can then request Medicare reimbursement. Medicare reimbursement will be approximately $18 for each flu vaccine.

Public health poster from Spanish flu era.
Image via Wikipedia

To request reimbursement, the beneficiary will need to obtain and complete form CMS 1490S.  So the beneficiary may receive reimbursement, you will need to provide the beneficiary with a receipt for the flu vaccine that has the following information written or printed on it:
”¢    The doctor’s or provider’s name and address
”¢    Service provided (“flu vaccine”)
”¢    Date flu vaccine received
”¢    Amount paid

What codes are used for flu shots?

For flu vaccine and vaccine administration, the following codes are used.

Effective September 1, 2009, (no 2010 changes have been announced) the Medicare Part B payment allowances for influenza vaccines are as follows:

  • For HCPCS 90655, the payment will be  $15.447:  Influenza virus vaccine, split virus, preservative free, for children 6- 35 months of age, for intramuscular use
  • For HCPCS code 90656, the payment will be  $12.541: Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use
  • For HCPCS code 90657, the payment will be  $15.684:  Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use;
  • For HCPCS code 90658, the payment will be  $11.368:  Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use
  • HCPCS 90660 (FluMist, a nasal influenza vaccine) may be covered if the local Medicare contractor determines its use is medically reasonable and necessary for the beneficiary. When payment is based on 95 percent of the Average Wholesale Price (AWP), the Medicare Part B payment allowance for CPT 90660 is $22.316 (effective September 1, 2009).

G0008 is the Medicare HCPCS for Administration of influenza virus vaccine, including FluMist.  Other payers usually require use of 90465, 90466, 90467, 90468, 90471, 90472, 90473 or 90474 for administration of the vaccine.

The associated ICD-9 codes for flu shots are:

V04.81    Influenza
V06.6      Pneumococcus and Influenza (both vaccines at one visit)

Other resources:

  • Get your practice and your staff ready for flu season by following the guidelines I write about here.
  • Free downloads from the CDC here.
  • MedLine Plus Articles, Downloads and Resources here
  • Article: Mandating Influenza Vaccine – One Hospital’s Experience (MedScape free account required)
  • National Foundation for Infectious Diseases: Influenza
  • National Influenza Vaccine Summit: Prevent Influenza
  • Vaccine Education Center at Children’s Hospital of Philadelphia (CHOP) -Influenza: What You Should Know (pdf)   EnglishSpanish
  • Medicare Preventive Services Quick Reference Information Chart: Medicare Part B Immunization Billing (Influenza, Pneumococcal, and Hepatitis B) is available here (pdf.)
  • For information on roster billing (billing for many patients at one time) see the Medicare Claims Processing Manual for Preventive and Screening Services (Chapter 18) here (pdf) Section 10-3.

NOTE: Beneficiaries have been advised to contact the Inspector General hotline at 1-800-HHS-TIPS (1-800-447-8477) to file a complaint if they believe their physician or provider charged an unfair amount for a flu vaccine.

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Posted in: Collections, Billing & Coding, Medicare & Reimbursement

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10 Comments

  1. Maryann Jacks, MD October 19, 2010

    Thanks for the information…but can you tell me how I would bill if I vaccinate a group of Medicare patients at a day camp? Is there a way to provide a group list of names and Medicare numbers rather than completing a HICF1500 form individually for each person (these are not my patients, but a group of blind citizens who need the immunization).

  2. Mary Pat Whaley October 19, 2010

    Hi Maryann,

    Here’s how to do roster billing:

    1. Using a paper claim (CMS-1500) , complete the following blocks:

    Item 1: An X in the Medicare block
    Item 2: (Patient’s Name): “SEE ATTACHED ROSTER”
    Item 11: (Insured’s Policy Group or FECA Number): “NONE”
    Item 20: (Outside Lab?): An “X” in the NO block
    Item 21: (Diagnosis or Nature of Illness):
    Line 1: Choose appropriate diagnosis code from §10.2.1
    Item 24B: (Place of Service (POS)):
    Line 1: “60”
    Line 2: “60”
    NOTE: POS Code “60″ must be used for roster billing.
    Item 24D: (Procedures, Services or Supplies):
    Line 1: Influenza Virus vaccine: “Select appropriate influenza virus vaccine
    code”
    Line 2: Influenza Virus Vaccine Administration: “G0008″
    Item 24E: (Diagnosis Code):
    Lines 1 and 2: “1”
    Item 24F: ($ Charges): The entity must enter the charge for each listed service. If
    the entity is not charging for the vaccine or its administration, it should
    enter 0.00 or “NC” (no charge) on the appropriate line for that item. If
    your system is unable to accept a line item charge of 0.00 for an
    immunization service, do not key the line item. Likewise, electronic
    media claim (EMC) billers should submit line items for free immunization
    services on EMC pneumococcal or influenza virus vaccine claims only if
    your system is able to accept them.
    Item 27: (Accept Assignment): An “X” in the YES block.
    Item 29: (Amount Paid): “$0.00″
    Item 31: (Signature of Physician or Supplier): The entity’s representative must sign
    the modified Form CMS-1500 (08-05).
    Item 32: Enter the name, address, and ZIP Code of the location where the service
    was provided (including centralized billers).
    Item32a: Enter the NPI of the service facility as soon as it is available. The NPI
    may be reported on the Form CMS-1500 (08-05) as early as October 1, 2006.
    Item 33: (Physician’s, Supplier’s Billing Name): The entity must complete this
    item to include the Provider Identification Number (not the Unique
    Physician Identification Number) or NPI when required.
    Item 33a: Effective May 23, 2007, and later, enter the NPI of the billing provider or
    group. (The NPI may be reported on the Form CMS-1500 (08-05) as
    early as October 1, 2006.)

    2. Attach a roster containing at a minimum the following information:

    ! Provider name and number;

    ! Date of service;

    ! Control number for contractor;

    ! Patient’s health insurance claim number;

    ! Patient’s name;

    ! Patient’s address;

    ! Date of birth;

    ! Patient’s sex; and

    ! Beneficiary’s signature or stamped “signature on file”.

    Send the 1500 form and the attached roster to your Medicare carrier!

    Best wishes,

    Mary Pat

  3. Kathleen Stillwell October 27, 2010

    I reviewed the national AAP’s FAX on the new 2011 immunization administration codes. As I understand it, the new codes (90460 and 90461) can be used for counseling by a physician or “other qualified healthcare professional” and the definition of “other qualified personnel” may differ from state to state. Is there any place to go and check by state if Medical Assistants qualify as “other qualified healthcare personnel? Thank you!

  4. Mary Pat Whaley October 28, 2010

    Hi Kathleen,

    This is a great question! I am not aware of a state-by-state definition of “other qualified healthcare professional” in this instance, but I do know that injections are handled in different ways in different environments. Technically, any person can be trained by a physician to perform most any clinical task in the office and as long as the competency training and sign-off is documented, it is fine. In the hospital setting, typically only LPNs and RNs are permitted to give counsel/give injections, but some of that has to do with the protection of the nursing responsibilities by nurses.

    That being said, anyone who has been training and signed-off on the competency of counseling and giving a flu shot should be able to respond to a situation in which a patient has a reaction to the flu shot. So, even if you have a medical assistant giving the flu shot, you must have someone nearby and have a defined protocol for dealing with adverse reactions.

    I am not familiar with what JCAHO or AAAHC accreditation standards are on this topic.

    I hope that helps.

    Thanks for writing, Kathleen.

    Best wishes,

    Mary Pat

  5. Rich Flaherty December 16, 2010

    Mary Pat asked me to post this on the blog after I sent her an email. If you are interested in getting more information, please contact me.

    Mary Pat,

    I read your post on the Manage My Practice website and it was great information. I am not sure if you are interested or would find this helpful to share with folks, but my company, ZirMed, is a electronic clearinghouse company. We have a program peaked in electronic roster billing to Medicare where a provider can fill out a spreadsheet with all the information and upload that to our site as a batch file. We then create the claims and send them out electronically to Medicare. Our environment gives the provider an online environment to view their claims, make resubmittals if necessary and get their EOBs back electronically. The cost is $.35 per claim and an additional $.05 per for electronic remittances.

    Again, thought I would pass on the information to you should you speak with anyone who is looking for an easy way to process roster bill flu shot claims. Thank you for all you do to help providers.

    Rich

    Rich Flaherty
    Vice President – Sales

    Office (877) 494-7633 ext. 5412
    Direct (502) 657-5412
    FAX (502) 657-7512

  6. Mary Pat Whaley December 16, 2010

    Thanks, Rich, for sharing!

    Best wishes,

    Mary Pat

  7. CHANDA DIHENIA September 19, 2012

    If we see a patient in office and bill a 99213 etc code and give the flu vaccine do we still bill the G0008 vaccine administration code with that or not?

    thank you .

  8. Mary Pat Whaley September 23, 2012

    Hi Chanda,

    Not all payers will pay the administration code when there is an office visit on the same day, however, making sure that there is a different substantiating diagnosis for the visit and the flu shot gives you the best chance of getting it paid.

    Some practices do not send a charge through that they believe will not be paid – they zero it out so it does not appear on the claim (saving them the work of posting the denial if the payer doesn’t pay) and others believe all work should be reflected on the claim sent to the payer – it’s a philosophical difference that each practice makes for themselves.

    Best wishes,

    Mary Pat

  9. Pattie August 15, 2013

    I have a question regarding the place of service code for flu shots given out of the clinic. When the nurses go to churches and/or office buildings to give requested flu shots, what place of service is used for commercial insurance and Medicare claims?

  10. Mary Pat Whaley August 19, 2013

    Hi Pattie,

    Here is what the Medicare Billing Manual states:
    “Individuals/entities administering influenza virus and pneumococcal vaccinations in a mass immunization setting (including centralized flu billers), regardless of the site where vaccines are given, should use POS 60 for roster claims, paper claims, and electronically filed claims.”

    Best wishes,

    Mary Pat

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