Q2034 And The New 2012 – 2013 Flu Shot Medicare Reimbursement Codes
9/29/2012 Medicare pricing just released for flu shots – see pricing added to the codes below.
Download this excellent 2012 – 2013 grid that shows vaccines by name and the appropriate codes!
NOTE: Practices using FLUARIX (preservative free) for Medicare patients should be using 90656 and not the NOS code of Q2039.
Q2034 Introduced As New Medicare Reimbursement Code for 2012 – 2013 Flu Shot Season
Influenza virus vaccine code Q2034 (Influenza virus vaccine, split virus, for intramuscular use (Agriflu)) for claims with dates of service on or after July 1, 2012, processed on or after October 1, 2012 has been introduced for the 2012 – 2013 flu season for Medicare patients.
Effective for claims with dates of service on or after July 1, 2012, influenza virus vaccine code Q2034 will be payable by Medicare. Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physicians practitioners and suppliers who administer the influenza virus vaccination must take assignment on the claim for the vaccine.
Effective for dates of service between July 1, 2012 and September 30, 2012, contractors shall use local pricing guidelines to determine payment rates for influenza virus vaccine code Q2034.
Contractors shall pay for influenza virus vaccine code Q2034 to hospitals (12X and 13X), SNFs (22X and 23X), HHA (34X), hospital-based RDFs (72X), and CAHs (85X) based on reasonable cost.
Until systems are implemented, contractors shall hold institutional claims containing code Q2034 with dates of service on or after July 1, 2012, received before October 1, 2012.
Once the system changes described in this instruction are implemented, contractors shall release the held claims, appending condition code 15.
How should the flu shot be coded?
- Choose the Q code for Medicare patients or CPT code for non-Medicare patients that is appropriate for the brand of vaccine you are giving or the special circumstances (pediatric dose, regular dose, high dose, preservative free, single dose syringe or multi-dose vial, etc.) NOTE: there are some 9xxxx codes that you will use for Medicare patients when the patient has Medicare but is less than 65 years of age. You will also use 9xxxx codes for Medicare patients when using an intradermal delivery system, intranasal delivery system, or high dose.
- Use the Administration Code G0008 for Medicare or 90471 for non-Medicare patients
- Use the Diagnosis Code: V04.81
Choose one code for the vaccine:
NEW! 90653 – Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use
90654 Influenza virus vaccine, split virus, preservative-free, for intradermal use (Medicare reimbursement $18.91)
90655 Influenza virus vaccine, trivalent, preservative free, when administered to children 6-35 months of age, for intramuscular use (Medicare reimbursement $16.45) single dose syringe
90656 Influenza virus vaccine, trivalent, preservative free, when administered to individuals 3 years and older, for intramuscular use (Use for Medicare flu shots using the vaccine Fluarix) (Medicare reimbursement $12.39) single dose syringe
90657 Influenza virus vaccine, trivalent, when administered to children 6-35 months of age, for intramuscular use ($6.02) multi-dose vial
90658 Influenza virus vaccine, trivalent, when administered to individuals 3 years and older, for intramuscular use (not recognized by Medicare) multi-dose vial
90660 Influenza virus vaccine, live, for intranasal use (Medicare reimbursement $23.45)
90662 Influenza virus vaccine, trivalent, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Medicare reimbursement $30.92) high dose
90672 Influenza virus vaccine, quadrivalent, live, for intranasal use (not recognized by Medicare)
90685 Influenza virus vaccine, quadrivalent, preservative free, when administered to children 6-35 months of age, for intramuscular use (not recognized by Medicare)
90686 Influenza virus vaccine, quadrivalent, preservative free, when administered to individuals 3 years and older, for intramuscular use (not recognized by Medicare)
90687 Influenza virus vaccine, quadrivalent, when administered to children 6-35 months of age, for intramuscular use (not recognized by Medicare)
90688 Influenza virus vaccine, quadrivalent, when administered to individuals 3 years and older, for intramuscular use (not recognized by Medicare)
Only for Medicare Patients:
NEW! Q2034 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Agriflu) (Medicare reimbursement not released)
Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria) (Medicare reimbursement $11.54)
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval) (Medicare reimbursement $9.83)
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirun) (Medicare reimbursement $14.05)
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) (Medicare reimbursement $12.04)
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified) (No reimbursement rate 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.
How often is the information updated?
There can be new information about flu shots every year, and the pricing usually changes annually.
Hi Mary Pat,
I visit your site often, and want to thank you for making my life as an practice manger easier. I have a question about the cost of the Flu vaccine, or vaccines in general. I was recently meeting with my Merck vaccine rep. And told her the unit price I have loaded for a particular vaccine. She said , per your contract with Merck you should be paying???. I said well I consider the sales tax as well. She said you should be state tax exempted. She reviewed my account and had me write a letter to the Merck vaccine manager requesting a tax status change on my account, and to have all state taxes paid in the last 3 years refunded. It took about 2 weeks, but yesterday I received a packet for Merck that listed all the state taxes we have paid in 3 years $2800 to be completed and sent to the dept of revenue for a taxe refund. I called Vaxserve to request the same change in status and refund and was told that GA i vaccines are not tax exempt. My question is should vaccines be tax exempt when purchased by a physicia?
I am so glad to hear our site is helpful!
Since every state’s taxes are different, I think you would need to call your state revenue department and ask them this question. Are you a non-profit of some type or a Federally Qualified Health Center? If you are not a standard private medical practice, there is certainly the possibility that you are tax-exempt, but I am not immediately aware of what else might cause you to be state tax exempt.
I wonder if any other reader has the answer to this?
Hello Mary Pat!
Is this the most current/accurate information from Medicare on Influenza/PPV billing for 2012-13?
Thanks for all the helpful information!
Yes, this is current – the two new codes for flu shots that were added this year are Q2034 (Medicare) and 90653 (non-Medicare).
Will Medicare reimburse for 90662? Does a patient have to be high risk? If they pay what is the fee schedule?
Medicare does not list 90662 as a reimbursable code in their fee schedule, and I have not heard of them reimbursing for use of any of the 9xxxx series, but maybe our readers have a different answer – Readers?
I did find out that practices giving FLUARIX (preservative free) to Medicare patients should be using 90656 and not the NOS code of Q2039.
Hi Mary Pat,
Our office has a supply of FLUARIX vaccine. This is not listed with a specific code. What code should we use?
In further response to your question of 9/12, I did find out that practices giving FLUARIX (preservative free) to Medicare patients should be using 90656 and not the NOS code of Q2039.
Help!!! Tricare and Georgia Medicaid are denying our flu shots. We are giving Afluria and are using 90658, which Tricare states is an invalid code. Medicaid states that NDC number does not match procedure code but Merck staes that what we have is right. Please advise!!!!
Have you called Tricare and asked what code they want you to use?
Yes, Georgia Medicaid and Tricare states that they can not advise us on what code to use.
You are sure that the claims didn’t deny for any other reason – it is absolutely the wrong code for the vaccine and nothing else? And you’ve tried calling on a specific denied claim asking for detailed information on the denial?
The only thing I can suggest is to send out a claim with the Medicare equivalents of the flu shot codes.
Readers have any other suggestions?
Help, what billing codes should we use to bill Medicare patients for the flu shot, Confused.
The way to bill for Medicare patients for flu shots is to choose the Q code that matches the brand of vaccine that you purchased. If the vaccine you bought does not have an associated Q code, you will use a code from the non-Medicare list shown in the article. Use G0008 for the administration of the vaccine and use V04.81 for the diagnosis.
Thank you Mary Pat, I think I got it So, I should code the Vaccine which is Q2037 administration G0008, and Diagnosis which is V04.81, right. Please let me know. Thank you so much for your help.
It sounds like you got it! Remember that if your patient comes in for an office visit and you happen to give them a flu shot, assign the appropriate diagnosis to the office visit (why they came into the office) and assign the V04.81 to the Q2037 and G0008. If you run a flu clinic and just give the shots without any provider participation, you’ll just code the vaccine and administration.
Thanks a Million Mary Pat.
Thank you for stopping by Mary!
Can you tell me with the GOOO8 administration fee, what is the charge on that. I can find everything else but the fee for that code. Please help.
I’m in the same boat! I’ve not seen found it anywhere, but as soon as I do, I will publish it on MMP.
Have they set the reimbursement rate for G0008 for 2012-13?
I’ve not seen it anywhere yet, and I’ve been looking because people are asking. If I see it published, I’ll put a post up about it here on the site.
Quick question about Medicare patients:
Do we still use G and Q codes for pts that have medicare through commercial insurances such as UHC or Anthem and not just plain Medicare?
Most Medicare replacement plans will accept either the Q/G codes or the 9xxxx series codes, but it doesn’t hurt to call and ask them what they prefer.
I am trying to bill Medicare through the “Mass Immunizers” but i don’t know where to enter the Diagnosis and when i hit F9 to update it gives me an error of 1A008.
I am using:
Revenue Code HCPC
I will really appreciate your help.
I suggest you call your Medicare carrier and see if they can help you. Without knowing the software that you are using, I don’t know how to help you. If you can’t get anyone at your MAC to help, I suggest calling your software vendor and asking for help. Do you belong to a user group for that software – maybe you could ask another home health group for advice?
Do any readers have other suggestions?
What is the Medicare reimbursable amount for administration of the flu shot
I have seen the reimbursement listed at $22.52.
Tricare is denying my claims for NDC # issues. Does anybody know if the NDC # changed for 90658?
Can anyone help Heni?
If your NDC code matches the # on your drugs packaging; then it may be the NDC order; whether it be in 5-3-2 or
4-4-2, you may have to check your software; and also check with Tricare as to what their requirements are for that drug. I had the very same problem with Tricare with another drug. Good luck!
Thanks for the help, Linda!
We have never billed for the G0008 in the past. Is this necessary? We have only ever billed for the vaccine and not the administration. Is this something new? Is so, I have no idea what the charge is for the G0008. Thanks for any help you can give me.
No, you are not required to charge for the vaccine administration, however, most practices elect to charge for the administration to compensate for the labor.
Medicare reimbursement for G0008 is in the $16-$19 range, depending on your locality. You can charge $20, or a multiple of the Medicare fee schedule.
I need help.
I use 90662(high dose for over 65) and G0008, with V04.81.
But medicare didn’t pay.
I don’t know what to do.
Please help me.
The best thing to do is to call your Medicare carrier, if this is traditional Medicare, or call the commercial insurer, if this is a Medicare replacement plan. Without knowing what the denial says, I can’t tell why the claim is not being paid.
I have just received a load of denials from UHC Medicare replacement plans for flu shots using 90471, 90658 with v04.81. Am I supposed to be using the Medicare codes of G0008, Q2037? Thanks!
The best approach is to call the Medicare replacement plan and ask them what they want. Some Medicare replacement plans will take either/or, but some are very definitive about what they want.
can you charge a facility fee along with the flu shot?
Unless a separate E/M service has been provided, there is no facility fee associated with giving a flu shot.
Hi, Every One
Lately medicaid is not paying for our flu shots for adults we are billing 90658. We have tried Q2036 and still there is a denial with the NDC. Any suggestions?
Have you contacted Medicaid and asked for a reason? What does the denial code on the Medicaid EOB state?
Medicare is denying q2036 due to payer deems the info submitted does not support this many/frequency o services. If we adminstered as a booster how can we appeal or correc claim?
Is your diagnosis supporting the medical necessity of the booster? You need to make sure your diagnosis supports the reason for the booster.