Influenza and Pneumonia Billing

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

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

Item >Information to Enter
1 "X" in Medicare block
2 - Patient's Name Enter "SEE ATTACHED ROSTER"
11 - Insured's Policy Group or Federal Employees' Compensation Act (FECA) Number Enter "NONE"
20 - Outside Lab? "X" in the NO block
21 - Diagnosis or Nature of Illness or Injury Line A: Enter "Z23"
Enter "0" for ICD Indicator between dotted lines
24B - Place of Service (POS) Enter "60" on Lines 1 and 2
24D - Procedures, Services, or Supplies Line 1: Appropriate pneumococcal vaccination or influenza virus vaccination code
Line 2: G0009 for pneumococcal vaccination administration or G0008 for influenza vaccination administration
24E - Diagnosis Pointer (Code) Line 1: A
Line 2: A
24F - Charges List charge for each service 
*Not total for all patients
If no charge, enter "0.00"
27 - Accept Assignment? Enter "X" in YES block
29 - Amount Paid Enter "$0.00"
31 - Signature of Physician or Supplier Entity's representation must sign
32 - Service Facility Location Information Name, address, and ZIP code
32a National Provider Identifier (NPI) of service facility
33 - Billing Provider Info & Phone Number Enter billing provider information and phone number
33a NPI of billing provider or group

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.

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

Influenza HCPCS and CPT Codes

HCPCS/CPT Description
G0008 Administration of influenza virus vaccine
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;
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
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
90756 Influenza virus vaccine, quadrivalent, derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use) Effective 1/1/2018
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 (Fluvirin)
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 individuals 3 years of age and older, for intramuscular use (not otherwise specified)

Pneumococcal HCPCS and CPT Codes

HCPCS/CPT Description
G0009 Administration of pneumococcal vaccine
90669 Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use
90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use;

 

Resources

 

Last Updated Nov 29, 2018