Coding and Billing for Flu and Pneumonia Shots 2020-2021
Tis the season. Your patients will be lining up for their annual flu shots and pneumonia immunizations. Knowing how to code and bill these services correctly will save you time and headaches.
INFLUENZA VACCINE
CMS updates payment for seasonal flu vaccine every year and changes become effective on August 1st.
BACKGROUND
Medicare’s Part B seasonal influenza vaccine payment is based on 95 percent of the Average Wholesale Price (AWP). If the vaccine is provided in a hospital outpatient department, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC), payment for the vaccine is based on reasonable cost. Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners, and suppliers who administer flu and pneumonia vaccinations must take assignment on the claim for the vaccine.
PNEUMOCOCCAL VACCINE
Medicare Part B covers 2 different pneumococcal shots. Part B covers the first shot at any time and a second shot against a different strain of the virus if it’s given at least one year after the first shot.
Revenue codes for both flu and pneumonia immunizations are:
· 0771 Preventive Care Services, Vaccine Administration
· 0636 Pharmacy, Drugs requiring detailed coding
COVERAGE REQUIREMENTS
Pneumococcal vaccine, influenza virus vaccine and their administration are covered only under Medicare Part B, regardless of the setting in which they are furnished. Medicare does not require that a DO or MD order either vaccine. So, a beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision.
INSTITUTIONAL CLAIMS
The following providers may administer and submit institutional claims for flu and pneumonia vaccines:
· Hospitals
· Critical Access Hospitals (CAH’s)
· Home Health Agencies (HHA’s)
· Hospices
· Comprehensive Outpatient Rehab Facilities (CORS’s)
· Indian Health Service (IHS) hospitals and hospital-based facilities
· Independent Renal Dialysis Facilities
Institutional providers, other than independent RHCs and freestanding FQHCs, should bill for the vaccines and their administration on the same bill. The only exceptions to this rule occur when the vaccine is administered during the course of an otherwise covered home health visit since the vaccine and administration aren’t included in the visit charge.
PROFESSIONAL CLAIMS
Billing for Additional Services
If a physician sees a beneficiary for the sole purpose of administering the influenza virus vaccine, and/or the pneumococcal vaccine, they may not routinely bill for an office visit. However, if the beneficiary receives other services constituting an “office visit” level of service, the physician may bill for a visit in addition to the vaccines and their administration.
Rural Health Clinics and Federally Qualified Health Centers
Independent and provider-based Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) do not include charges for flu and pneumococcal vaccines on claim forms.
Administration of these vaccines does not count as a visit when the only service involved is the administration of influenza virus and/or pneumococcal vaccine(s).
If there was another reason for the visit, the RHC/FQHC should bill for the visit without adding the cost of the influenza virus and pneumococcal vaccines to the charge for the visit on the bill.
Payment is made at the time of cost settlement.
ADDITIONAL INFORMATION
The official instruction, CR 11882, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10263CP.pdf. If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.
https://www.cms.gov/Regulations-and-uidance/Guidance/Manuals/Downloads/clm104c18.pdf