CMS Releases Pricing and Codes for 2011-2012 Influenza Vaccine

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By: Anne M. Dunne, RN-BC, MBA, MSCN, Director of Healthcare Consulting

Late last week, the Centers for Medicare and Medicaid Services released new pricing guideline for seasonal influenza vaccines for Medicare beneficiaries for the 2011-2012 flu season. The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95% of the Average Wholesale Price (AWP) as reflected in the published compendia. The only exception is when the vaccine is administered in a hospital outpatient department. When the vaccine is provided and administered in a hospital outpatient department, payment for the vaccine is based on reasonable cost.

 

Frequently asked questions:

1. Do Medicare patients have to pay for the flu shot?

Annual Part B deductible and coinsurance amounts do not apply for the seasonal influenza virus and the pneumococcal vaccinations. All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine. Do not collect any monies from Medicare patients for the provision or administration of the seasonal influenza or pneumococcal vaccine.

2. What will Medicare pay for the influenza vaccine?

 

The payment allowances listed below are based upon the annually updated payment allowance for the listed CPT codes and Q-codes when the vaccines are furnished outside the hospital outpatient department.

 

Medicare allowables effective for dates of service between September 1, 2011 and August 31, 2012

CPT 90654: $18.383
CPT 90655: $15.705
CPT 90656: $12.375
CPT 90657: $6.653
CPT 90660: $22.316
CPT 90662: $30.923

Q2035 (Afluria): $11.543
Q2036 (Flulaval): locally priced
Q2037 (Fluvirin): $13.652
Q2038 (Fluzone): $13.306
Q2039 (N.O.S.): locally priced

 

3. How should the influenza vaccine be billed and coded?

1. Choose the Q code or CPT code that is appropriate for the brand of vaccine the provider is administering or the special circumstances (pediatric dose, regular dose, high dose, preservative free, etc.)

2. Use the Administration Code G0008

3. Use the Diagnosis Code: V04.81

 

Choose the code for the influenza vaccine you administer, noting preservative content, age appropriateness and route of administration.

90655 – Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use

90656 – Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use

90657 – Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use

90660 – Influenza virus vaccine, live, for intranasal use

90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

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 (Fluvirun)

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 individuals3 years of age and older, for intramuscular use (Not Otherwise Specified)

 

4. How many flu shots will Medicare pay for? Medicare will pay for one flu vaccine per influenza season in the fall or winter.

 

Medicare may cover additional seasonal influenza virus vaccinations if medically necessary.

Consult your practice management advisor to find out what screening category your organization falls under and for answers to further questions about provider enrollment and screening.

 

For more information on this or other practice management topics, she can be reached at (516) 336-2463 or via email at adunne@grassicpas.com

 

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