Billing Flu Shots To Medicare And Commercial Insurance Companies
Since it is now flu season I have been getting a lot of questions on how to bill flu shots to commercial insurance companies and Medicare. The codes used for a particular vaccine will vary depending on intramuscular vs. intranasal use, age of the patient, formulation, preservative-free, and split or live virus. If you are unsure of what code to use I suggest looking at the package informationthat came with the vaccine. Usually, you can find the code on the packaging, and if you cant find it in the documentation then call the supplier.
This is how most of our primary care practices bill for flu shots. Your situation may be different so make sure to check all the influenza vaccine codes 90654-90668 and use the appropriate code for the vaccine administered to the patient.
Payment Allowances And Effective Dates For The 2019
Fluzone Quadrivalent 0.25ml Afluria Quadrivalent 0.25ml
Fluarix Quadrivalent Flulaval Quadrivalent Fluzone Quadrivalent Afluria Quadrivalent
Flulaval Quadrivalent Fluzone Quadrivalent Afluria Quadrivalent
|$26.657||08/01/2019 – 07/31/2020|
If any new vaccine received FDA approval after the initial publication, the payment limits and effective dates will be posted to this webpage.
Time To Make Sure Your Practice Is Current On The 2021
With the novel coronavirus continuing to circulate and cause severe illness in the United States and worldwide, getting a flu shot is once again more important than ever. The 202122 influenza season will coincide with the continued circulation of SARS-CoV-2, the virus that causes COVID-19, so start planning now.
Common signs and symptoms of COVID-19 can also occur with influenza, which is one of the many reasons why the Centers for Disease Control and Prevention recommends that everyone six months and older receive a flu shot. Influenza vaccines provide the best protection against the flu and its potentially serious complications. Furthermore, getting the jab will decrease the prevalence of the flu as well as reduce symptoms that might be confused with those of COVID-19. Make sure your practice is prepared for the flux of injections by updating your billing systems with the 2021 Average Sales Price Drug Pricing Files and reading the latest vaccination guidance.
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Whats Going Around This Year
All seasonal influenza vaccines expected to be available for the 20212022 season are quadrivalent, containing hemagglutinin derived from one influenza Apdm09 virus, one influenza A virus, one influenza B/Victoria lineage virus, and one influenza B/Yamagata lineage virus.
For the 202122 season, U.S.-licensed influenza vaccines will contain:
- A/Victoria/2570/2019 pdm09-like virus or an influenza A/Wisconsin/588/2019 pdm09-like virus
- A/Cambodia/e0826360/2020 -like virus
- B/Washington/02/2019 -like virus and
- B/Phuket/3073/2013 -like virus.
Get more information regarding CDC recommendations for prevention and control of seasonal influenza and answers to frequently asked questions about the 2021-2022 flu season.
For further clarification, see the recommendations of the Advisory Committee on Immunization Practices regarding prevention and control of seasonal influenza with vaccines.
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Flu Vaccine Administration Coding
When reporting vaccination encounters, use ICD-10-CM diagnosis code Z23 Encounter for immunization. For Medicare, code the administration of the flu shot with G0008 Administration of influenza virus vaccine.
Most vaccines are given as injections and are reported to non-Medicare payers with administration codes
- 90471 Immunization administration 1 vaccine and
- +90472 Immunization administration each additional vaccine .
But there are a few oral and intranasal vaccines that are reported using administration codes 90473 and 90474. Only use 90471-90474 when immunization is not accompanied by face-to-face counseling of the patient/family, or for vaccine administration to patients over 18 years of age.
Pediatric vaccine administration with counseling codes are:
- 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional first or only component of each vaccine or toxoid administered
- +90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional each additional vaccine or toxoid component administered
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Everything You Need To Know About 2021
Practice Excellence | September 20, 2021
Influenza vaccines are now available for the 2021-2022 season. Heres what you need to know:
- All flu vaccines this year are quadrivalent and are designed to protect against four different flu viruses. The CDC recommends an annual flu vaccination for everyone 6 months of age and older, with rare exceptions.
- Flu vaccines and COVID-19 vaccines can be given at the same time.
- Here is a list of influenza vaccines available for 2021-2022, along with associated age ranges, CPT codes and supply methods for each. It also indicates which vaccines are egg-based.
- Medicare reimbursement rates are available at the Centers for Medicare and Medicaid Services Seasonal Influenza Vaccine Pricing for 2021-2022.
- For general information about the 2021-2022 influenza vaccine, read the CDCs FAQs.
- Flu vaccine administration CPT codes remain unchanged for 2021-2022.
For Medicare patients, use the administration code G0008.
For non-Medicare patients:If the patient receiving the influenza vaccine is 18 years of age or younger and receives counseling from a physician or other qualified health care professional , report 90460.
- 90460 Immunization administration through 18 years of age via any route of administration, w/ counseling by physician or other qualified health care professional first vaccine/toxoid component.
However, if both of the above criteria are not met, the immunization administration code reported must come from the 90471-90474 series.
What Do Experts Recommend
Routine annual influenza vaccination is recommended for all persons aged 6 months who do not have contraindications, per the CDC. The American Academy of Pediatrics also recommends annual influenza immunization of all children without medical contraindications, starting at 6 months of age.
Influenza vaccination is an important intervention to protect vulnerable populations and reduce the burden of respiratory illnesses during circulation of severe acute respiratory syndrome coronavirus 2, which is expected to continue during the 20212022 influenza season. -AAP
AAP maintains that any licensed, age-appropriate vaccine is acceptable they do not have a preference for one product or formulation over another. Notably, the AAP clarifies that the flu jab may be administered simultaneously with or any time before or after administration of the currently available novel coronavirus disease 2019 vaccines.
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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 .
On this page, view the below information:
Air Vaccine Code Formats
You can use vaccine codes in your software products to send immunisation notifications to the AIR.
A vaccine code and dose is needed for every AIR episode a health professional submits through your software product.
As a Software developer , you need to build and maintain the current vaccine codes in your AIR software products. This includes:
- vaccine brand name
- vaccine code
- maximum allowable dose .
Theres no restriction on the maximum allowable doses of standard vaccines that can be transmitted.
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Indications And Limitations Of Coverage And/or Medical Necessity
Medicare Part B provides preventive coverage only for certain vaccines. These include:
- Influenza: once per flu season
- Claim should contain HCPCS G0008 and ICD-10 Z23
- Effective for dates of service 8/01/2017 thru 12/31/2017 claims for Flucelvax Quadrivalent influenza vaccine should be billed utilizing HCPCS Q2039 .
- NOTE Claims billed for dates of service prior to 12/31/2017, if submitted on or after 01/01/2018, must bill HCPCS Q2039 for the claim to process correctly.
- Pneumococcal: An initial pneumococcal vaccine to Medicare beneficiaries who have never received the vaccine under Medicare Part B and a different, second pneumococcal vaccine 1 year after the first vaccine was administered
- Claim should contain HCPCS G0009 and ICD-10 Z23
- Pneumococcal and Seasonal Influenza Virus Vaccines received during the same visit (use seasonal influenza virus and pneumococcal vaccine codes
- Claim should contain HCPCS G0008 AND G0009 AND ICD-10 Z23
- Hepatitis B: for persons at intermediate- to high-risk only . People who are considered high or medium risk for hepatitis B are:
Claim should contain HCPCS G0010 and ICD-10 Z23
Payments For Influenza Vaccine Cpt Codes
Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for all Medicare beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and its administration once in a lifetime for all Medicare beneficiaries. Medicare may provide coverage of additional pneumococcal vaccinations based on risk or uncertainty of beneficiary pneumococcal vaccination status. Medicare provides coverage for these vaccines and their administration with no co-pay or deductible.Remember Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is NOT a Part D covered drug.Effective for dates of service on or after August 1, 2012, the Medicare Part B payment allowance for:CPT 90655 is $16.456HCPCS Q2035 is $11.543HCPCS Q2036 is $9.833HCPCS Q2037 is $14.051HCPCS Q2038 is $12.046Note: The Medicare Part B payment allowance for HCPCS Q2034 and HCPCS Q2039 will be determined by the local claims processing contractor.Payment for the following may be made if the local claims processing contractor determines its use is medically reasonable and necessary for the beneficiary:CPT 90654 ) CPT 90660 orCPT 90662 .Effective for dates of service on or after August 1, 2012, when payment is based on 95 percent of the AWP, the Medicare Part B payment allowance for:CPT 90654 is $18.981
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Medicare Part B: Vaccine Coverage
Medicare Part B provides preventive coverage only for certain vaccines. These include:
- Influenza: once per flu season
- Hepatitis B: for persons at intermediate- to high-risk
Administration services for these preventive vaccines are reported to Medicare using HCPCS codes as follows:
- G0008 administration of influenza virus vaccine
- G0009 administration of pneumococcal vaccine
- G0010 administration of Hepatitis B vaccine
The diagnosis code to report with these preventive vaccines is:
- Z23 Encounter for immunization
Other immunizations are covered under Medicare Part B only if they are directly related to the treatment of an injury or direct exposure Coverage of other vaccines provided as a preventive service may be covered under a patient’s Part D coverage.
Items Of Note About Codes 90460 And 90461
To correctly report vaccine counseling and administration with these codes, it is important to recognize what the codes do and do not include.
- These codes are limited to immunization administration, meaning purchased vaccine products must be separately reported.
- A face-to-face service where a physician or other qualified health care professional provides counseling to the patient and/or caregivers is required to report 90460-90461.
- In the absence of counseling, the administrations must be reported with codes 90471-90474.
- 90460-90461 are reported for administration to patients 18 years of age and under.
- Code 90460 is reported for each separate administration of single component vaccines and/or first component of a combination vaccine.
- When reporting administration of combination vaccines, code 90460 is reported for the first component and add-on code 90461 is reported for each additional component .
- Note that route of administration does not matter, since the codes include via any route of administration.
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Nc Immunization Program/vaccines For Children
Under NC Immunization Program/Vaccines for Children guidelines, the NC Division of Public Health Immunization Branch distributes all childhood vaccines that are recommended by the Advisory Committee on Immunization Practices to local health departments, Federally Qualified Health Centers , Rural Health Clinics hospitals and private providers.
For the 2021-2022 influenza season, NCIP/VFC influenza vaccine all quadrivalent is available at no charge to providers for children 6 months through 18 years of age who are eligible for the VFC program, according to the NCIP coverage criteria. The current NCIP coverage criteria and definitions of VFC categories can be found on DPHs Immunization Branch web page.
For providers interested in enrolling in the VFC program, information can be found on the CDC information page and the NC DPH website.
Eligible VFC children include Medicaid beneficiaries and NC Health Choice beneficiaries who are American Indian and Alaska Native . These beneficiaries can be identified as AI/AN in one of two ways:
All other NC Health Choice beneficiaries are considered insured and must be administered privately purchased vaccines.
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