(Medicare Claims Processing Manual)

The applicable types of bill acceptable when billing for influenza virus , pneumococcal  and COVID- 19 vaccines are 012x, 013x, 022x, 023x, 034x, 072x, 075x, 081x, 082x, and 085x. Contractors shall refer to  10.3.2 for applicable billing requirements for mass immunization.    The following revenue codes are used for reporting vaccines and administration of  the vaccines for all providers except RHCs and FQHCs.  Independent and provider  based RHCs and FQHCs follow 10.2.2.2 below when billing for influenza  virus, pneumococcal, hepatitis B, and COVID- 19 vaccines.   Units and HCPCS codes are required with revenue code  0636:   Revenue  Code  Description  0636  Pharmacy, Drugs requiring detailed coding  (a) 0771  Preventive Care Services,  Vaccine Administration   In addition, for the influenza virus vaccine, providers report condition code M1 when roster billing.  See roster billing instructions in 10.3 of this  chapter.   When vaccines are provided to inpatients of a hospital or SNF, they are covered under  the vaccine benefit. However, the hospital bills on type of bill 012x using the discharge  date of the hospital stay or the date benefits are exhausted.  A SNF submits type of bill  022x for its Part A  inpatients.   10.2.2.1 - Payment for Pneumococcal Pneumonia Virus, Influenza Virus, Hepatitis B Virus and COVID- 19 Vaccines and Their Administration on Institutional Claims        (Rev. 11843, Issued:02- 09-23, Effective: 03 -09-23, Implementation:03 -09-23) Payment for Vaccines   Payment for these vaccines is as follows:   Facility  Type of Bill  Payment  Hospitals, other than Indian Health Service (IHS) Hospitals, IHS CAHs, and Critical Access Hospitals (CAHs)  012x, 013x Reasonable cost   IHS Hospitals  012x, 013x 95% of the AWP  IHS CAHs  012x, 085x 95% of the AWP  CAHs Method I and Method II (other than professional revenue codes)  012x, 085x Reasonable cost  Skilled Nursing Facilities  022x, 023x Reasonable cost  Home Health Agencies  034x Reasonable cost  Hospices  081x, 082x 95% of the AWP  Comprehensive Outpatient Rehabilitation Facilities  075x 95% of the AWP  Independent Renal Dialysis Facilities (RDFs)  072x 95% of the AWP  Hospital -based Renal Dialysis Facilities (RDFs)  072x Reasonable cost   Payment for Vaccine Administration   Payment for the administration of influenza virus, pneumococcal and COVID -19 vaccines is as follows:   Facility  Type of Bill  Payment  Hospitals, other than IHS Hospitals, IHS CAHs, and CAHs  012x, 013x Outpatient Prospective Payment System (OPPS) for hospitals subject to OPPS Reasonable cost for hospitals not subject to OPPS  IHS Hospitals  012x, 013x MPFS  IHS CAHs  012x, 085x MPFS  CAHs Method I and Method II (other than professional revenue codes)  012x, 085x Reasonable cost  CAHs Method II (Professional Revenue Codes 096x, 097x, 098x)  085x MPFS  Skilled Nursing Facilities  022x, 023x MPFS  Home Health Agencies  034x OPPS  Hospices  081x, 082x MPFS  Comprehensive Outpatient Rehabilitation Facilities  075x MPFS  Independent RDFs  072x MPFS  Hospital -based RDFs  072x Reasonable cost     Payment for the administration of hepatitis B vaccine is as follows:   Facility  Type of Bill  Payment  Hospitals other than IHS hospitals, IHS CAHs, and CAHs  012x, 013x Outpatient Prospective Payment System (OPPS) for hospitals subject to OPPS Reasonable cost for hospitals not subject to OPPS  IHS Hospitals  012x, 013x MPFS  IHS CAHs  012x, 085x MPFS  CAHs Method I and Method II (other than professional revenue codes)  012x, 085x Reasonable cost  CAHs Method II (Professional Revenue Codes 096x, 097x, 098x)  085x MPFS  Skilled Nursing Facilities  022x, 023x MPFS  Home Health Agencies  034x OPPS  Hospices  081x, 082x MPFS  Comprehensive Outpatient Rehabilitation Facilities  075x MPFS  Independent RDFs  072x MPFS  Hospital -based RDFs  072x Reasonable cost   10.2.2.2 - Special Instructions for Independent and Provider -Based Rural Health Clinics/Federally Qualified Health Center (RHCs/FQHCs)  Clinics/Federally Qualified Health Center (RHCs/FQHCs)  (Rev. 12070; Issued: 06- 07-23; Effective: 07 -10-23; Implementation: 07 -10-23)  Influenza virus, pneumococcal and COVID -19 vaccines do not count as RHC/FQHC visits.  The cost for these vaccines is included in the cost report and a visit is not billed for these services.  RHCs do not report vaccines on the claim, TOB 71x.  However, for  FQHCs,  if there was another reason for the visit, the vaccine and the administration code should be reported on the claim, TOB 77x, for informational and data collection purposes only.  Coinsurance and deductible do not apply to these vaccines.   Payment for the hepatitis B vaccine is included in the RHC all- inclusive and FQHC PPS rate.  RHCs/FQHCs do not bill for a visit when the only service involved is the administration of the hepatitis B vaccine.  However, the charges of the vaccine and its ad ministration can be included in the line item for the otherwise qualifying visit.  A visit cannot be billed if vaccine administration is the only service the RHC/FQHC provides.   10.2.3 - Institutional Claims Submitted by Home Health Agencies and Hospices  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  The following provides billing instructions for Home Health Agencies (HHAs) in various situations:   Where the sole purpose for an HHA visit is to administer a vaccine  (influenza virus, pneumococcal, hepatitis B or COVID -19), Medicare will not pay for a skilled nursing visit by an HHA nurse under the HHA benefit.  However, the vaccine and its administration are covered under the vaccine benefit.  The administration  should include charges only for the supplies being used and the cost of the injection.  Medicare does not allow HHAs to charge for travel time or other expenses  (e.g., gasoline).  In this situat ion, the HHA bills under bill type 034x and reports revenue code 0636 along with the appropriate HCPCS code for the vaccine  and revenue code 0771 along with the appropriate HCPCS code for  the administration.   NOTE: A separate bill is not allowed for the  visit  If a vaccine (influenza virus, pneumococcal, hepatitis B, or COVID -19) is administered  during the course of an otherwise covered home health visit (e.g., to perform  wound care), the visit would be covered as normal but the HHA must not include  the vaccine or its administration in their visit charge.  In this case, the HHA is  entitled to payment for the vaccine and its administration under the vaccine benefit.   In this situation, the HHA bills under bill type 034x and reports revenue code  0636 along with the appropriate HCPCS code for the vaccine and revenue code  0771 along with the appropriate HCPCS code for the  administration.   NOTE:  A separate bill is required for the visit  Where a beneficiary does not meet the eligibility criteria for home  health coverage, a home health nurse may be paid for the vaccine (influenza  virus, pneumococcal, hepatitis B or COVID -19) and its administration.  No skilled nursing  visit charge is billable.  Administration of the services should include charges only for the supplies being used and the cost of the injection. Medicare does not pay for travel time or other expenses (e.g., gasoline).  In this situation, the HHA  bills under bill type 034x and reports revenue code 0636 along with the  appropriate HCPCS code for the vaccine and revenue code 0771 along with the  appropriate HCPCS code for the  administration.   If a beneficiary meets the eligibility criteria for coverage, but his or her spouse does  not, and the spouse wants an injection the same time as a nursing visit, HHAs bill in accordance with the last bullet point  above.  The following provides billing instructions for  hospices:   Hospices can provide the influenza virus, pneumococcal, hepatitis B and COVID -19 vaccines to those beneficiaries who request them, including those who have elected the  hospice benefit.  These services may be covered when furnished by the  hospice.   For dates of service before October 1, 2016, services for vaccines and their administration provided by a hospice should be billed on a professional claim to the  local MAC.  Payment is made using the same methodology as if they were a  supplier.  Hospices that do not have a supplier number should contact their MAC to obtain one  in order to bill for these  benefits.  For dates of service on or after October 1, 2016, services for vaccines and their administration provided by a hospice may be billed on an institutional  claim.    10.2.4 - Payment Procedures for Renal Dialysis Facilities (RDF)  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  MACs processing institutional claims pay for pneumococcal, influenza virus, hepatitis B and COVID- 19 vaccines for freestanding RDFs based on the lower of the actual  charge or 95 percent of the average wholesale price and based on reasonable cost for  provider - based RDFs.  Deductible and coinsurance do not apply for pneumococcal, influenza virus, hepatitis B and COVID -19 vaccines.  MACs must contact their professional claims processing staff to obtain information in order to make payment for the administrati on of these  vaccines.   10.2.4.1 - Hepatitis B Vaccine Furnished to ESRD Patients  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  Hepatitis B vaccine and its administration (including staff time and supplies such as syringes) are paid to ESRD facilities in addition to, and separately from, the dialysis composite rate payment.   Payment for the hepatitis B vaccine for ESRD patients follows the same general principles that are applicable to any injectable drug or biological.  Hospital -based facilities are paid for their direct and indirect costs on a reasonable cost basis, and independent facilities are paid the lower of the actual charge or 95 percent of the AWP .  The allowance for an injectable is based on the cost of the injectable and any supplies used for administration, plus a maximum $2 for the labor involved, if the facilitys staff administers the vaccine.  In addition, the MAC (Part A) makes an appropriate allowance for facility overhead.   Where the vaccine is administered in a hospital outpatient department for home dialysis patients or for patients with chronic renal failure (but not yet on dialysis), payment is on a reasonable cost basis.  Outpatient hospital vaccines for non- dialysis pur poses are paid under hospital outpatient PPS rules.      10.2.5 -  Claims Submitted to MACs (Part B)                                                                                       (Rev. 11355; Issued:04- 14-22; Effective:05- 16-22; Implementation:05 -16-22)  Medicare does not require that the influenza virus, pneumococcal or COVID -19 vaccine be administered under a physicians order or supervision.    Medicare still requires that the hepatitis B vaccine be administered under a physicians order with supervision.  As a physician order is still required for claims for hepatitis B vaccinations, information on the ordering and/or referring physician must be entered on the claim.  A. Reporting Specialty Code/Place of Service (POS) to CWF  Specialty