Influenza and Pneumonia Billing - JE Part B

Medicare covers both the costs of the vaccine and its administration by recognized providers. There is no coinsurance or co-payment applied to this benefit and a beneficiary does not have to meet his or her deductible to receive it. Assignment must be accepted on all vaccine claims and a physician order is not required.

Influenza and pneumonia vaccinations and administration are covered under Part B, not Part D.

If a physician sees a beneficiary for the sole purpose of administering one of these vaccines, an office visit cannot be billed. However, if the beneficiary receives other services which constitute an office visit, then one can be billed.

If both vaccines are administered on the same day, providers are entitled to receive payment for both administration fees.

The diagnosis code used for these vaccines and administration is Z23 (encounter for immunization).

On this page, view the below information:

• Mass Immunizers
• Centralized Billing
• Roster Billing
• Payment
• Influenza HCPCS and CPT Codes
• Pneumococcal HCPCS and CPT Codes

Mass Immunizers

Mass immunizers offer influenza vaccines, pneumococcal vaccines, or both, to groups of individuals, such as from the public or members of a retirement community.

Mass immunizers can be a traditional provider, such as a physician, or a non-traditional provider, such as a drug store, public health clinic or senior citizen home. CMS created the mass immunizer specialty for those providers that wouldn't otherwise qualify for Medicare enrollment.

Mass Immunizer Requirements:

• Be properly licensed in the State of operation
• Be enrolled in the Medicare Program
• Accept assignment on both vaccinations and administration
• User roster billing
• Bill a MAC, such as Noridian
• Use this process for influenza and pneumococcal vaccinations and administration only

Centralized Billing

Centralized billing is an option that allows a mass immunizer to send all its influenza and pneumococcal vaccination claims to a single MAC for payment, regardless of where the vaccination was administered. Medicare pays based on the payment locality where the service was provided. This does not include claims for the Railroad Retirement Board, United Mine Workers, or Indian Health Service. These claims need to go to the appropriate processing entity identified by CMS when notification of enrollment as a Centralized Biller is received by CMS.

Centralized Billing Requirements:

• Operate in at least three payment localities where there are three different MACs responsible for processing their claims
• Be enrolled in Medicare as a Mass Immunizer or other provider
• Accept assignment on both the vaccinations and their administration
• Request to participate in the program on an annual basis
• Use roster bills
• Submit claims electronically
• Provide beneficiaries with a record of the pneumococcal vaccination
• Provide beneficiaries written notification of the name of the MAC processing the claims

Roster Billing

Roster bills can be submitted on paper or electronically. If billing for both influenza and pneumococcal, these do need to be submitted on separate claims. Do not bill for other services on the same claim. Also, do not use the roster bill for a single beneficiary.

Claim Form Instructions

After the claim is completed, attach a beneficiary roster form with the following information:

• Provider's name and NPI
• Date of service
• MAC's control number
• Beneficiary
  • Medicare number
  • Name
  • Address
  • Date of birth
  • Gender; and
  • Signature or stamped "signature on file"

If the beneficiary's actual signature cannot be obtained, the phrase "signature on file" can be used if the provider has a signed authorization on file from the beneficiary to bill Medicare for the services.

Roster Forms

Noridian offers rosters on the Forms section of our website. CMS indicates that the pneumococcal roster needs to include the following language:

WARNING: Beneficiaries must be asked if they have received a pneumococcal vaccination.

• Rely on patients' memory to determine prior vaccination status.

Payment

CMS allows 95% of the Average Wholesale Price except when furnished in a hospital outpatient department, Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC), in which those are based on reasonable cost.

Vaccine administration payment based on Locality-Adjusted Payment Rates for Influenza, Pneumococcal and Hepatitis B Vaccine Administration (found on CMS Vaccine Pricing page).

To see the allowances, go to the CMS Seasonal Influenza Vaccines Pricing webpage.

Influenza HCPCS and CPT Codes

Pneumococcal HCPCS and CPT Codes

Medicare covers pneumonia (pneumococcal, PPV), under Part B:

• Both vaccine and administration costs covered by recognized providers
  • Includes nurses, pharmacists, under incident to supervision
• No beneficiary coinsurance or unmet deductible applied
• Assignment must be accepted on all vaccine claims and physician order not required
• Two types of pneumococcal vaccines:
  • Conjugate PCV13 (CPT 90670), PCV15 (CPT 90671) or PCV20 (CPT 90677)
  • Polysaccharide PPSV23 (CPT 90732)
• If sole purpose to administer vaccine, no E/M office visit allowed
• Influenza and pneumonia vaccines administered same day, may bill both administration
• Diagnosis code always used =  Z23 (encounter for immunization)

Resources

• CMS Preventive Services
• CMS Vaccine Pricing
• CMS Roster Billing for Mass Immunizers
• CMS Change Request (CR) 8098 - Vaccines Furnished at Hospice
• CMS MM13118 Medicare Part B Coverage of Pneumococcal Vaccinations
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.4.2
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 10