M e d i c a re

P re v e n t i v e

S e rv i c e s :

Adult Immunizations

A Guide to

Billing

Influenza and

P n e u m o c o c c a l

Va c c i n a t i o n s
CPT codes, descriptions, and other data only are copyright 2003 American

Medical Association (or such other date of publication of CPT). All rights

reserved. Applicable FARS/DFARS apply. CPT® is Current Procedural Terminology,

and was developed by the American Medical Association in 1966. Each year, an

annual publication is prepared, that makes changes corresponding with

significant updates in medical technology and practice. The most recent version of

CPT, CPT 2003, contains 8,107 codes and descriptors.

http://www.ama-assn.org/ama/pub/category/3884.html

The ICD-9-CM codes and descriptors used in this publication are copyright 2003

under uniform copyright convention. All rights reserved.

For additional free Medicare education and training opportunities, including Web

Based Training (WBT) courses and information concerning future satellite

broadcasts, please visit the Medicare Online Training website at:

http://www.cms.hhs.gov/medlearn

This booklet has been prepared as a service to the public and is not intended to

grant rights or impose obligations. This booklet may contain references or links to

statutes, regulations, or other policy materials. The information provided is only

intended to be a general summary. It is not intended to take the place of either

the written law or regulations. We encourage readers to review the specific

statutes, regulations, and other interpretive materials for a full and accurate

statement of their contents.

On October 1, 2003 CMS transitioned from a paper based manual system to a

Web-based system. The new system is called the CMS Online Manual System

(also called the Medicare and Medicaid Program Instructions website) and is

located at:

http://www.cms.hhs.gov/manuals

Please use this site to find information regarding eligibility, entitlement, claims

processing, benefit policy and program integrity.

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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Mass Immunizers

Enrollment Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Points of Special Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Completing the Medicare Provider Application (CMS-855I and B) . . . . . . . . . . 3

Roster Billing

Simplified Billing Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Medicare’s Coverage and Reimbursement

Coverage Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Payment Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Routine Billing for the Influenza and PPV Benefit . . . . . . . . . . . . . . . . . . . . . 11

Medicare+Choice Guidelines

Basic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Resources and Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Claim Form and Roster Bill Examples . . . . . . . . . . . . . . . . . . . . . . . . . 16

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TABLE OF CONTENTS
Purpose

This document provides guidelines for the administration and billing of influenza and pneumococcal va c c i n e s. Though the information in this pamphlet will be useful for all immunizers, the

issues invo l ved in Medicare billing and administration can be complex and may vary from state

to state. For this reason, we recommend that you contact your local Medicare intermediary (Pa r t

A), carrier (Part B), or CMS regional office for more detailed information.

Background

Influenza and pneumococcal disease are two of the five leading causes of death in the United

States among persons 65 ye a rs of age or older. Epidemics of influenza are responsible for an

ave rage of approximately 20,000 deaths per year in the U.S., of which more than 90 perc e n t

occur among those age 65 and older. Pneumococcal infection causes an estimated 125,000

hospitalizations for pneumonia annually in the U.S. Most deaths due to pneumococcal disease

occur in persons age 65 and older.

The U.S. Congress established the Medicare pro g ram in 1965. Cove rage for preve n t i ve services has

been added since 1980, and use of preve n t i ve services has increased over time. The Medicare

p ro g ram has cove red pneumococcal polysaccharide vaccine (PPV) and its administration since July

1 , 1 9 81. Cove rage for the influenza virus vaccine and its administration was added May 1, 1 9 9 3 .

The U.S. immunization rates have increased but have far to go. In 1999, 54.1 percent of persons aged 65 ye a rs and older had ever re c e i ved a pneumococcal va c c i n e. In 1999, influenza

immunization rates for this group we re 66.9 percent—double the 1989 immunization rate of 33

p e rcent. The Leading Health Indicators, established by Healthy People 2010, target both

vaccination rates to reach 90 percent for persons age 65 ye a rs or older.

Advisory Committee on Immunization Practices (ACIP)

The ACIP develops written recommendations for the routine administration of vaccines to

pediatric and adult populations, along with schedules re g a rding the appropriate periodicity,

d o s a g e, and contraindications applicable to the va c c i n e s. ACIP is the only entity in the federa l

g overnment that makes such re c o m m e n d a t i o n s. Clinicians should refer to published guidelines for

c u r rent recommendations related to immunization. The Infectious Diseases Society of America

( I D SA) and the American Thoracic Society (ATS) also discuss vaccination in their guidelines. The

latest ACIP recommendations re g a rding immunizations and vaccines can be found at the AC I P

we b s i t e. (See the Re s o u rces section at the end of this pamphlet for the ACIP web addre s s. )

Internet Only Manual

Since the advent of the Internet Only Manual (IOM) on October 1, 2003, Publication

100-4/Claims Processing Manual, Chapter 18, Section 10, is the resource for flu and

pneumonia vaccines regardless of provider type. All information can be found at:

http://www.cms.hhs.gov/manuals/104_claims/clm104c01.pdf.

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INTRODUCTION
Mass Immunizer Enrollment Process

Note: This enrollment process applies only to entities that enroll with

Medicare as a provider specialty type 73, Mass Immunization Roster

Biller. These entities will (1) bill a carrier; (2) use roster bills; (3) bill

only for flu and/or PPV vaccinations; and (4) accept assignment on both

the vaccines and their administration.

As used by CMS, the term “mass immunizer” is defined in the following

manner: A mass immunizer generally is a provider who offers flu and PPV

vaccinations to a large number of individuals (the general public or members of

a specific group, such as residents of a retirement community). Often the flu or

PPV shots are offered during an immunization program or clinic.

P rov i d e rs and suppliers must enroll in Medicare even if mass immunizations are the only service they will provide to Medicare beneficiaries. T h ey

can enroll by filling out the CMS-855I for individuals or the CMS-855B for a gro u p .

P rov i d e rs and suppliers who wish to roster bill for mass immunizations should

contact the Medicare carrier servicing their area for a copy of the enro l l m e n t

application and special instructions for mass immunizers. The enrollment applications can also be found at: w w w. c m s. h h s. g ov / p rov i d e rs / e n ro l l m e n t / f o r m s a n d

the listing of carriers and their telephone numbers can be found at:

w w w. c m s. h h s. g ov / p rov i d e rs / e n ro l l m e n t / c o n t a c t s

Providers/suppliers who wish to bill for other Part B services must enroll as

a regular provider or supplier by completing the entire CMS-855I for individuals

or the CMS-855B for groups. Although CMS wants to make it as easy as possible

for providers and suppliers to immunize Medicare beneficiaries and bill

Medicare, we must ensure that they are qualified to receive a provider number

and receive the proper payment.

Points of Special Interest to Mass Immunizers

A mass immunizer may be a traditional Medicare physician, provider or

supplier such as a hospital outpatient department or may be a nontraditional

provider or supplier such as a senior citizen’s center, public health clinic,

community pharmacy or supermarket. 

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MASS IMMUNIZERS

MASS IMMUNIZERS
An entity that enrolls with Medicare as a provider specialty type 73, Mass

Immunization Roster Biller, may only submit claims for flu and PPV vaccines

and their administration, must submit claims for immunizations on roster bills,

and must accept assignment on both the vaccine and its administration. These

claims will only be submitted to Medicare carriers.

Non-governmental entities (providers, physicians, or suppliers) that

provide immunizations free of charge to all patients, regardless of their

ability to pay, must provide the benefit, free of charge, to Medicare

beneficiaries and may not bill Medicare. However, a non-governmental

entity that does not charge patients who are unable to pay or reduces its

charge for patients of limited means (sliding fee scale) but does expect to be

paid if a patient has health insurance which covers the items or services

provided, may bill Medicare and receive Medicare program payment.

State and local government entities (such as public health clinics) m ay bill

M e d i c a re for immunizations given to beneficiaries even if they prov i d e

immunizations free to all patients, re g a rdless of their ability to pay.

Since the flu and PPV benefits do not re q u i re any

beneficiary coinsurance or deductible, a Medicare

beneficiary has a right to re c e i ve this benefit without

incurring any out-of-pocket ex p e n s e. In addition, the entity

that furnishes the va c c i n e, and the entity that administers the

va c c i n e, are each re q u i red by law to submit a claim to

M e d i c a re on behalf of the beneficiary.

The entity may bill Medicare for the amount that is not

subsidized from its budget. For example, an entity that

incurs a cost of $7.50 per flu shot and pays $2.50 of the cost

from its budget may bill the carrier the $5.00 cost which is

not paid out of its budget.

Sometimes an entity re c e i ves donated flu or PPV va c c i n e, or re c e i ves donated

services for the administration of the va c c i n e. In these cases, the provider may bill

M e d i c a re for the portion of the vaccination that was not donated.

Mass Immunizers must provide the Medicare beneficiary with a record of

the PPV vaccination.

Completing the Medicare Provider Application

The Medicare Provider/Supplier Enrollment Application (CMS-855I or

CMS- 855B) must be completed to obtain a Medicare provider number.

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MASS IMMUNIZERS
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The CMS-855I or CMS-855B application form contains seve ral pages of

i n s t r u c t i o n s that provide details about each section that you will find helpful.

Contact your local Medicare carrier’s provider enrollment department with

additional questions or to request forms. Application forms can also be dow n l o a d e d

f rom the CMS website at: w w w. c m s. h h s. g ov / p rov i d e rs / e n ro l l m e n t / f o r m s.

Ensure the most current CMS-855I or CMS-855B application form is used

and that appropriate supporting documents are included with the application

along with the appropriate signatures by authorized officials. Mail the completed

form to the Medicare provider enrollment department at your local Medicare

carrier. A listing of carriers and their telephone numbers can be found at:

www.cms.hhs.gov/providers/enrollment/contacts.

Billing Using Simplified Procedures

Individuals and entities submitting claims for PPV and flu

vaccinations must submit a separate preprinted CMS-1450

or CMS-1500 for each type of va c c i n a t i o n . Each CMS-1450

or CMS-1500 must have an attached roster bill listing the

beneficiaries who re c e i ved that type of va c c i n a t i o n .

Generally, FOR PART A CLAIMS ONLY, five beneficiaries

per day must be vaccinated in order to roster bill.

However, this requirement is waived for inpatient hospitals

that mass immunize and utilize the roster billing method.

FOR PART B CLAIMS ONLY, immunization of at least five beneficiaries on the

same date is no longer required for any individual or entity to qualify for roster

billing. However, the rosters should not be used for single patient bills and the

date of service for each vaccination administered must be entered.

The following items can be preprinted on a CMS-1500 for entities using

roster billing for flu virus vaccine, PPV, and/or administration claims submitted

to Medicare carriers:

Item 1: Place an X in the Medicare block;

Item 2: (Patient’s Name): Enter the statement “See Attached Roster”;

Item 11: ( I n s u re d ’s Po l i cy Group or FECA Number): Enter the wo rd “None”;

ROSTER BILLING

ROSTER BILLING
Item 20: (Outside Lab?): Place an “X” in the NO block;

Item 21: (Diagnosis or Nature of Illness): On line 1, enter “V03.82”for PPV 

or V04.81 for claims with dates of service on or after October 1, 20 03 ;

Item 24B: (Place of Service (POS)): All entities that administer vaccinations 

in a mass immunization setting should enter POS code “60” (Mass 

Immunization Center), no matter the setting;

Item 24D: ( P ro c e d u re s, Services, or Supplies): On line 1, enter the appropriate 

flu or PPV vaccine code (90657, 90658, or 90659 for flu virus or 

9 0732 for PPV; on line 2, enter the appropriate administration code

(G0008 for flu virus or G0009 for PPV). A separate CMS-1450 or

C M S - 1 500 must be submitted for each type of va c c i n a t i o n;

Item 27: (Accept Assignment): Place an “X” in the YES block; and

Item 29: (Amount Paid): Enter “$0.00”.

The following additional items on the CMS-1500 must be entered on the

claim before submission to the Medicare carrier:

Item 24F: ($ Charges): Enter the charge for each listed service. Enter the unit

cost, not the total for all patients. If no charge is made, enter 

“$0.00” or “NC”;

Item 31: (Signature of Physician or Supplier): The entity’s representative

must sign the modified CMS-1500; and

Item 32: (Name and Address of Facility): Effective for claims received on or 

after April 1, 2004, the name and address of the facility where the 

services are rendered must be entered; and

Item 33: ( P hys i c i a n ’s, Supplier’s Billing Name): The entity must enter the 

P rovider Identification Number (PIN) or group (PIN) as appro p r i a t e.

The following information should be included on a patient roster form that

will be attached to a pre-printed CMS-1500 under the simplified ro s t e r

billing pro c e d u re : Patient Name and Ad d ress; Health Insurance Claim Number;

Date of Birth; Sex; Date of Service; Signature or stamped “Signature on File”; and

P rov i d e r ’s Name and Identification Number.

A signature on file stamp or notation qualifies as a signature on a roster claim

form in cases where the provider has access to a signature on file in the

b e n e f i c i a r y ’s re c o rd (e.g., when the vaccine is administered in a phys i c i a n ’s office).

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ROSTER BILLING
Inpatient/outpatient departments of hospitals and outpatient departments

of other providers may use a signature on file stamp or notation if they

have access to a signature on file in the beneficiary’s record.

Other services should not be listed, along with the flu vaccine/PPV and

administration, on the modified CMS-1500. Other covered services are subject

to more comprehensive data requirements that the roster billing process is not

designed to accommodate. Other services should be billed using normal Part B

claims filing procedures and forms.

In some instances, two entities, such as a gro c e r y

s t o re and a pharmacy, jointly sponsor a flu or PPV

vaccination clinic. Assuming that charges are made

for both the vaccine and its administration, the entity

that furnishes the va c c i n e, and the entity that administ e rs the va c c i n e, are each re q u i red to submit claims.

Both parties must file separately for the specific

component furnished for which a charge was made.

When billing only for the administra t i o n, billers should indicate in block 24 of

the CMS-1500 that they did not furnish the va c c i n e. For roster billed claims, this

can be accomplished by lining through the preprinted item 24 line item

component that was not furnished by the billing entity or individual.

The following items can be preprinted on a CMS-1450 in specific field

l o c a t o rs (FL) for prov i d e rs using the simplified billing pro c e d u re for flu virus va cc i n e, PPV and/or administration claims submitted to Medicare fiscal intermediaries:

FL 12: (Patient Name): The words “See Attached Roster”;

FL 22: (Patient Status): Patient Status code 01;

FLs 24-30: (Condition Code): Condition code M1;

FLs 24-30: (Condition Code): Condition code A6;

FL 42: (Revenue Code): Revenue code 636, along with the appropriate 

HCPCS code in FL 44 (HCPCS Code);

FL 42: (Revenue Code): Revenue code 771, along with the appropriate 

HCPCS code G0008 in FL 44 (HCPCS Code);

FL 50: (Payer): “Medicare” on line A;

FL 51: (Provider Number): The words “See Attached Roster” on line A;

FL 82: UPIN SLF000; and

FL 67: (Principal Diagnosis Code): Diagnosis code V04.8.

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ROSTER BILLING
Providers conducting mass immunizations are required to complete the following

FLs on the preprinted Form CMS-1450:

FL 4: (Type of Bill);

FL 47: (Total Charges);

FL 85: (Provider Representative); and

FL 86: (Date).

Coverage Policy

For the purpose of the flu or PPV benefit, any individual or

entity meeting state licensure requirements may qualify to

have payment made for furnishing and administering the flu

vaccine or PPV to Medicare beneficiaries enrolled under

Part B, as long as certain Medicare requirements are met.

Medicare does not require a physician to be present.

However, the law in individual states may require a

physician’s presence, a physician order or other physician

involvement.

Medicare generally pays for one flu vaccine per season. This may mean that

a beneficiary will receive more than one flu vaccination in a 12-month period.

For example, a beneficiary may receive a flu vaccination in January 2003 for the

2002-2003 flu seasons and another flu vaccination in November 2003 for the

2003-2004 flu seasons. In this case, Medicare will pay for both shots because the

beneficiary received only one flu shot per season (January and November).

Medicare will pay for more than one flu vaccination per flu season if it is

reasonable and medically necessary.

High-risk individuals need PPV only once in a lifetime. Administer an

initial dose of PPV only to person at high-risk of PPV disease. This group

includes all individuals aged 65 or over; immunocompetent adults at increased

risk of pneumococcal disease or its complications because of chronic illness

(e.g., cardiovascular disease, pulmonary disease, diabetes mellitus, alcoholism,

cirrhosis, or cerebrospinal fluid leaks); and individuals with compromised

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MEDICARE’S COVERAGE AND REIMBURSEMENT

MEDICARE’S COVERAGE 

AND REIMBURSEMENT
immune systems (e.g., splenic dysfunction or

anatomic asplenia, Hodgkin’s disease, lymphoma,

multiple myeloma, chronic renal failure, HIV

infection, nephritic syndrome, sickle cell disease, or

organ transplantation).

Revaccinate only persons at highest risk of

serious PPV infection. This group includes persons with functional or anatomic

asplenia (e.g., sickle cell disease, splenectomy), congenital immunodeficiency,

HIV infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma,

generalized malignancy, chronic renal failure, nephritic syndrome, or other

conditions associated with immunosupression such as organ or bone marrow

transplantation, and those receiving immunosuppressive chemotherapy) and

those likely to have a rapid decline in PPV antibody levels, provided that at least

5 years have passed since receipt of a previous dose of PPV.

It is not necessary for a beneficiary to provide something in writing to

show his or her PPV vaccination status, nor is it necessary for the provider to

review the beneficiary’s medical records. Individuals and entities providing PPV

to Medicare beneficiaries may rely on a verbal account of vaccination status

provided by a competent beneficiary.

If a beneficiary who is not at highest risk is revaccinated because of

uncertainty about his or her PPV vaccination status, Medicare will cover the PPV

revaccination.

The flu vaccine, PPV, and their administration are a Part B covered service

only. Nontraditional providers and suppliers such as drug stores, senior

centers, shopping malls, and self-employed nurses, may bill a carrier for

flu vaccinations or PPV if they meet State licensure requirements to furnish

and administer flu vaccinations. Providers and suppliers should contact their

local carrier provider enrollment department to enroll in the Medicare program.

A registered nurse employed by a physician may use the physician’s

provider number if the nurse in a location other than the physician’s

office provides the flu or PPV vaccinations. If the nurse is not working for

the physician when the services are provided (e.g., a nurse is “moonlighting,”

administering flu vaccinations or PPV at a shopping mall at his or her own

direction and not that of the physician), the nurse may obtain a provider number

and bill the carrier directly. However, if the nurse is working for the physician

when the services are provided, the nurse would use the physician’s provider

number. The following providers of services may bill intermediaries for the

flu and PPV vaccines:

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MEDICARE’S COVERAGE AND REIMBURSEMENT
■ H o s p i t a l s ;

■ Skilled Nursing Facilities (SNFs);

■ Critical Access Hospitals (CAHs);

■ Home Health Agencies (HHAs);

■ Comprehensive Outpatient Rehabilitation Facilities (CORFs);

■ Rural Health Clinics (RHCs);

■ Federally Qualified Health Centers (FQHCs);

■ Independent Renal Dialysis Facilities (RDFs).

Home Health Agencies (HHAs): Where the sole purpose for an HHA visit is to

administer a vaccine (flu, PPV, or hepatitis B), Medicare will not pay for a skilled

n u rsing visit by an HHA nurse under the HHA benefit. Howeve r, the vaccine and

its administration are cove red under the vaccine benefit. The administra t i o n

should include charges only for the supplies being used and the cost of the

injection. HHAs are not permitted to charge for travel time or other ex p e n s e s

( e.g., gasoline).

Payment Policy

The law requires providers and suppliers to accept assignment for the PPV

and flu vaccines. Assignment for the administration of the vaccines is not

mandatory unless the provider is enrolled as a mass immunizer and

submits roster bills.

Medicare pays 100 percent of the Medicare approved charge or the submitted

charge, whichever is lower. Neither the $100 annual deductible nor the 20

percent coinsurance applies. Therefore, if a beneficiary receives a flu vaccination

or PPV from a physician, provider, or supplier who agrees to accept assignment

(i.e., agrees to accept Medicare payment as payment in full), there is no cost to

the beneficiary. If a beneficiary receives a flu vaccination or PPV from a

physician, provider, or supplier who does not accept assignment for the

administration of the vaccine, the physician may collect his or her usual charge

for the administration but may not roster bill for the service.

Physicians, providers, and suppliers who do not accept assignment should never

advertise the service as free since the beneficiary incurs an out-of-pocket

expense after Medicare has paid at 100 percent of the Medicare-allowed amount.

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MEDICARE’S COVERAGE AND REIMBURSEMENT
Participating institutional providers and physicians, providers, and suppliers that accept assignment must bill Medicare if they charge a fee to cover any

or all costs related to the provision and/or administration of the flu vaccine or

PPV. They may not collect payment from beneficiaries.

Nonparticipating physicians, providers, and suppliers that do not accept

assignment may collect payment from the beneficiary, but they must submit an

unassigned claim on the beneficiary’s behalf.

The limiting charge provision does not apply to the flu or PPV benefit.

Nonparticipating physicians and suppliers that do not accept assignment for the

administration of the flu or PPV vaccine may collect their usual charges (i.e., the

amount charged a patient who is not a Medicare beneficiary) for the administration of the vaccines. (They must always accept assignment for the vaccines and

may not collect up front from the beneficiary). The beneficiary is responsible for

paying the difference between what the physician or supplier charges and the

amount Medicare allows.

The five-percent payment reduction for physicians who do not accept

assignment does not apply to the administration of the flu and PPV

vaccines. Only items and services covered under limiting charge are subject to

the five-percent payment reduction.

M e d i c a re payment by carriers for the a d m i n i s t ra t i o n of the flu vaccine and

PPV is linked to payment for services under the physician fee schedule but

is not actually paid under the physician fee schedule. The charge for the

a d m i n i s t ration is the lesser of the actual charge or the fee schedule amount for a

c o m p a rable injection. Since fee schedules are adjusted for each Medicare pay m e n t

l o c a l i t y, payment for the a d m i n i s t ra t i o n of the vaccine varies by locality.

Payment by a Medicare Fiscal Intermediary payment to a provider for the

flu vaccine or PPV and its administration is made on the basis of

reasonable cost. Medicare payments, for given items or services, are

determined by statute; it would require Congressional legislation for Medicare to

pay a nationwide rate.

A physician, provider, or supplier may NOT charge a Medicare beneficiary

more for an immunization than he or she charges a non-Medicare patient.

Medicare will pay two administration fees if a beneficiary receives both the

flu vaccine and the PPV vaccine on the same day.

A physician, prov i d e r, or supplier may NOT collect payment for an immunization from a beneficiary and instruct the beneficiary to submit the claim

to Medicare for pay m e n t. Medicare law re q u i res that phys i c i a n s, prov i d e rs, and

s u p p l i e rs submit a claim for services to Medicare on the beneficiary’s behalf.

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MEDICARE’S COVERAGE AND REIMBURSEMENT
HCPCS code G0008 (administration of flu vaccine) and HCPCS code G0009

( a d m i n i s t ration of PPV va c c i n e ) m ay be paid in addition to other services,

including evaluation and management services and are NOT subject to

rebundling charg e s.

When a physician sees a beneficiary for the sole purpose of administering

flu vaccine or PPV, he or she may NOT routinely bill for an office visit.

However, if a patient actually receives other services constituting an “office visit”

level of service, the physician may bill for a visit and Medicare will pay for the

visit if it is reasonable and medically necessary.

Routine Billing for the Flu and PPV Vaccine

CMS-1450 and CMS-1500: All data fields that are required for any Part A or B

claim are required for the flu vaccine, PPV and their administration. Providers

should bill in accordance with the bill completion instructions in the various

provider manuals. Coding specific to these benefits is provided below. Charges

for other services may be listed on the same bill as influenza or PPV vaccinations. However, the applicable codes for the additional services must be

included. The following procedure codes are used for flu vaccine and its

administration:

HCPCS Code Description

90657 Flu virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use

90658 Flu virus vaccine, split virus, 3 years and above dosage, for 

intramuscular or jet injection use

90659 Flu virus vaccine, whole virus, for intramuscular or for jet 

injection

G0008 Administration of flu virus vaccine

The following diagnosis code is used if the sole purpose for the visit is to receive

the flu vaccine:

Diagnosis Code Description

V04.8 Flu vaccination

V04.81 For claims with dates of service after October 1, 2003

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MEDICARE’S COVERAGE AND REIMBURSEMENT
The following procedure codes are used for PPV and its administration:

HCPCS Code Description

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult 

dosage, for subcutaneous or intramuscular use

G0009 Administration of PPV vaccine

The following diagnosis code is used if the sole purpose for the visit is to

re c e i ve P P V:

Diagnosis Code Description

V03.82 PPV vaccination

Part A—Fiscal Intermediaries

On the CMS-1450 Form, re g a rdless of where the flu

vaccine or PPV is administered to a dialysis patient, of a

hospital or hospital-based renal dialysis facility, the hospital

bills the intermediary using bill type 13X. The following bill

types are applicable for the flu and pneumonia va c c i n e s :

13X, 22X, 23X, 34X, 72X, 75X and 85X.

Independent and provider-based RHCs and FQHCs do not

include charges for influenza and PPV. Payment is made

at cost settlement.

Revenue Codes: Providers bill for the vaccines using revenue code 636 and for

the administration using revenue code 771. 

All providers who bill the intermediary for the flu and PPV vaccines report

the administration under revenue code 771. This includes inpatient hospital and

inpatient Skilled Nursing Facilities.

Bill Types: Medicare hospitals bill for the vaccines under bill type 13X for their

inpatients and Skilled Nursing Facilities bill for the vaccine under bill type 22X.

Other charges may be listed on the same bill as flu vaccine or PPV. Howeve r,

the provider must include the applicable codes for the additional charg e ( s ) .

Part B—Carriers

With the exception of hospice prov i d e rs, certified Part A prov i d e rs must bill

their intermediary for this Part B benefit. Hospice prov i d e rs bill the carrier

via the CMS-150 0.

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MEDICARE’S COVERAGE AND REIMBURSEMENT
Non-Medicare participating provider facilities bill their local carrier.

HHAs that have a Medicare-certified component and a non-Medicare

certified component might elect to furnish the flu and PPV benefit through the

non-certified component and bill the Part B carrier.

Basic Procedures

Beneficiaries enrolled in Medicare+Choice coordinated care plans generally re c e i ve

most of their health care through prov i d e rs who contract with their plan.

E n rollees of Medicare+Choice plans may obtain the influenza va c c i n e

d i rectly from prov i d e rs in the plan without prior authorization from their

primary care prov i d e r. Enrollees are not re q u i red to obtain a re f e r ral from their

primary care provider in order to re c e i ve the influenza vaccine from a plan

p rov i d e r. Howeve r, the right to directly access the influenza vaccine does not

include obtaining it outside of the plan’s network of prov i d e rs. Medicare+C h o i c e

o rganizations have the discretion to re q u i re that self-re f e r rals be made only to

p rov i d e rs within the Medicare+Choice plan’s network as long as there is sufficient

access in their plan’s network. Howeve r, if a Medicare+Choice organization offers

a point-of-service (POS) option under its Medicare+Choice plan, an enro l l e e

selecting this option could self-refer to an out-of-network prov i d e r, consistent with

the payment rules established by the Medicare+Choice org a n i z a t i o n .

Medicare+Choice organizations have the authority to require prior

approval from the enrollee’s primary care provider to obtain the

pneumococcal vaccine.

M e d i c a re+Choice organizations may not impose cost sharing for influenza

vaccine and pneumococcal vaccine on their Medicare+Choice plan enro l l e e s.

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MEDICARE+CHOICE GUIDELINES

MEDICARE+CHOICE GUIDELINES
Advisory Committee on Immunization Practices

(ACIP) Guidelines

■ ACIP List of Recommendations

■ http://www.cdc.gov/nip/publications/ACIP-list.htm

CDC National Immunization Program

■ http://www.cdc.gov/nip 

Forms

■ CMS Paper Forms and Instructions,

http://cms.hhs.gov/providers/edi/edi5.asp

Health Insurance Portability and Accountability Act

(HIPAA)

Information about HIPAA and its re q u i rements is available through CMS,

i n d u s t r y, gro u p s, associations, and other org a n i z a t i o n s. Below are seve ral sourc e s :

■ http://cms.hhs.gov/hipaa/—website for Centers for Medicare & 

Medicaid Services (CMS)

■ http://aspe.os.dhhs.gov/admnsimp —DHHS Administrative

Simplification website

■ http://www.wedi.org/snip/—Industry HIPAA forum for implementation 

of standards

■ http://www.wpc-edi.com/hipaa/HIPAA_40.asp and

http://www.hipaa-dsmo.org/—Washington Publishing Company,

download free implementation guides, Q&As, etc.

Email: AskHIPAA@cms.hhs.gov—ask questions of the CMS HIPAA experts

Telephone: HIPAA Administrative Simplification Hotline, (410) 786-4232

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RESOURCES AND CONTA C T S

RESOURCES AND CONTA C T S
Questions regarding HIPAA privacy requirements should be directed to the U.S.

Department of Health & Human Services Office for Civil Rights, (800) 368-1029

or (800) 362-1710 or its website at http://www.hhs.gov/ocr/hipaa2.html.

Infectious Diseases Society of America (IDSA) discusses guidelines

■ IDSA—http://www.idsociety.org/

American Thoracic Society (ATS) discusses guidelines

■ ATS—http://www.thoracic.org/

Medicare Carrier Manual (MCM)

■ http://www.cms.hhs.gov/manuals/104_claims/clm104c01.pdf

Medicare Learning Network (MedLearn)

■ CMS MedLearn Immunization Quick Reference Guide: 

http://www.cms.hhs.gov/medlearn/refimmu.asp

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RESOURCES AND CONTA C T S
This is only an example of a roster bill. Contact the appropriate intermediary or

carrier for their particular roster bill format.

Influenza Virus Vaccine Roster

Provider Payee Name

Provider Number 

Date of Service 

Number Insured’s I.D. number Patient’s Name (Last, First, Middle Initial)

Patient’s Address (Number, Street, City, ZIP Code)

Patient’s Date of Birth

Patient’s Sex

Patient’s Signature, or “signature on file”

00

01

02

03

04

05

06

07

08

09

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CLAIM FORM AND ROSTER BILL EXAMPLES

CLAIM FORM AND

ROSTER BILL EXAMPLES
Pneumococcal Pneumonia Virus Vaccine Roster

This is only an example of a roster bill. Contact the appropriate intermediary or

carrier for their particular roster bill format.

Provider Payee Name 

Date of Service 

Provider Number 

Referring Physician’s Name and UPIN

Number Insured’s I.D. number 

Patient’s Name (Last, First, Middle Initial)

Patient’s Address (Number, Street, City, ZIP Code)

Patient’s Date of Birth

Patient’s Sex

Patient’s Signature, or “signature on file”

00

01

02

03

04

05

06

07

08

09

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CLAIM FORM AND ROSTER BILL EXAMPLES
WARNING! Ask beneficiaries if they have been vaccinated with PPV.

■ Rely on patient’s memory to determine prior vaccination status.

■ If patients are uncertain whether they have been vaccinated within the 

past 5 years, administer the vaccine.

■ If patients are certain they have been vaccinated within the past 5 years,

do not revaccinate.

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CLAIM FORM AND ROSTER BILL EXAMPLES