(Medicare Claims Processing Manual)

If a physician sees a beneficiary for the sole purpose of administering a Medicare covered preventive vaccine, they may  not routinely bill for an office visit.  However, if the beneficiary actually 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, and Medicare will pay for the visit  in addition to the vaccines and their administration if it is reasonable and medically necessary.   Nonparticipating Physicians and Suppliers   Nonparticipating physicians and suppliers (including local health facilities) that do not accept assignment may collect payment from the beneficiary for the administration of  the vaccines, but must submit an unassigned claim on the beneficiarys behalf.  Effective  for claims with dates of service on or after February 1, 2001, per 114 of the  Benefits Improvement and Protection Act of 2000, all drugs and biologicals must be paid based  on mandatory assignment.  Therefore, regardless of whether the physician and supplier usually accept assignment, they must accept assignment for the vaccines, may not  collect any fee up front, and must submit the claim for the  beneficiary.   Entities, such as local health facilities, that have never submitted Medicare claims  must obtain a National Provider Identifier (NPI) for Part B billing  purposes.   Separate Claims for Vaccines and Their  Administration   In situations in which the vaccine and the administration are furnished by two different entities, the entities should submit separate claims.  For example, a supplier (e.g.,  a pharmacist) may bill separately for the vaccine, using the Healthcare Common  Procedure Coding System (HCPCS) code for the vaccine, and the physician or supplier (e.g.,  a drugstore) who actually administers the vaccine may bill separately for  the administration, using the HCPCS code for the administration.  This procedure results  in contractors receiving two claims, one for the vaccine and one for its  administration.   For example, when billing for influenza virus vaccine administration only, billers  should list only HCPCS code G0008 in block 24D of the Form CMS -1500.  When billing for  the influenza virus vaccine only, billers should list only HCPCS code 90658 in block 24D  of the Form CMS -1500.  The same applies for the other Medicare covered preventive vaccinations.    In situations such as a public health emergency when vaccines are supplied at no charge to providers, entities shall submit claims for the administration of the vaccine only. For example, a provider or supplier may only submit a claim for the HCPCS code for the administration of the vaccine. If the billing systems providers and suppliers use will not allow submission of only the vaccine or only the administration, $.01 should be submitted as the charge for the service that was not provided.  The contractor shall deny claims for vaccine reimbursement costs when the vaccine has been provided at no charge to providers and suppliers.    10.2.1 - Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Codes (Rev. 11362; Issued: 04- 22-22; Effective: 01 -11-22; Implementation:07- 05-22)  Vaccines and their administration are reported using separate codes. The following codes are for reporting the vaccines only.  HCPCS  Definition  90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use  90653  Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use  90654  Influenza virus vaccine, split virus, preservative -free, for intradermal use, for adults ages 18  64; 90655  Influenza virus vaccine, split virus, preservative free, for children 6 - 35 months of age, for intramuscular use;  90656  Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use;  90657  Influenza virus vaccine, split virus, for children 6 -35 months of age, for intramuscular use;  90658  Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use  90660  Influenza virus vaccine, live, for intranasal use;  90661  Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use  90662  Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use    90670  Pneumococcal conjugate vaccine, 13 valent, for intramuscular use      90671  Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use   90672  Influenza virus vaccine, live, quadrivalent, for intranasal use  90673  Influenza virus vaccine, trivalent, derived from recombinant DNA  (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use  90674  Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use                            90677  Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use  90682  Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use  90685  Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6- 35 months of age, for intramuscular use 90686  Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use  90687  Influenza virus vaccine, quadrivalent, split virus, when administered to children 6 -35 months of age, for intramuscular use  90688   90694 Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use  Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, for intramuscular use       90732 Pneumococcal polysaccharide vaccine, 23 -valent, adult or immunosuppressed patient dosage, for us in individuals 2 years or older, for subcutaneous or intramuscular use;  90739  Hepatitis B vaccine, adult dosage (2 dose schedule), for  intramuscular use  90740  Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use;  90743  Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use; 90744  Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use;  90746  Hepatitis B vaccine, adult dosage, for intramuscular use; and  90747  Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use.  90756  Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use      90759  Hepatitis B vaccine (HepB), 3 -antigen (S, Pre -S1, Pre -S2), 10 mcg dosage, 3 dose schedule, for intramuscular use  Note: COVID- 19 vaccine and administration HCPCS are temporarily posted at: https://www.cms.gov/medicare/medicare- part-b-drug -average -sales -price/covid -19-vaccines -and-monoclonal -antibodies .  Note:   For the Medicare- covered codes for the influenza vaccines approved by the Food and Drug Administration (FDA) for the current influenza vaccine season, please go to:  https://www.cms.gov/Medicare/Medicare -Fee-for-Service- Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html   The following codes are for reporting administration of the vaccines only. The administration of the vaccines is billed using:   HCPCS  Definition  G0008  Administration of influenza virus vaccine;  G0009  Administration of pneumococcal vaccine; and  *G0010  Administration of hepatitis B vaccine.  *90471  Immunization administration. (For OPPS hospitals billing for the hepatitis B vaccine administration)  *90472  Each additional vaccine. (For OPPS hospitals billing for the hepatitis B vaccine administration)     * NOTE: Beginning January 1, 2011, providers should report G0010 for billing under the OPPS rather than 90471 or 90472 to ensure correct waiver of coinsurance and deductible for the administration of hepatitis B vaccine.   NOTE: COVID- 19 vaccine and administration HCPCS are temporarily posted at: https://www.cms.gov/medicare/medicare- part-b-drug -average -sales -price/COVID -19-vaccines -and-monoclonal -antibodies .   The following diagnosis code must be reported. If the sole purpose for the visit is to receive a vaccine or if a vaccine is the only service billed on a claim, the applicable following diagnosis code may be used.   ICD-10-CM Diagnosis Code  Description  Z23  Encounter for Immunization            NOTE : ICD -10-CM diagnosis code Z23 is to be used for all encounters for preventive vaccine immunizations, including COVID -19 immunizations.  All claims must have the appropriate diagnosis code, procedure, and admin code to process correctly.    10.2.1.1  Claims Received with Missing Data  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  If a diagnosis code for a pneumococcus, hepatitis B, influenza virus, or COVID -19 vaccination is not reported on a claim, contractors may enter the diagnosis on the claim and continue to process the claim for payment.   If the diagnosis code and the narrative description are correct, but the HCPCS code is incorrect, the MACs (Part A or Part B) may correct the HCPCS code and pay the claim. For example, if the reported diagnosis code is Z23  and the narrative description (i f annotated on the claim) says "flu shot" but the HCPCS code is incorrect, contractors may change the HCPCS code and pay for the flu vaccine. Effective October 1, 2006, A/B MACs (B) should follow the instructions in Pub. 100- 04, Chapter 1, Section   (MAC (Part B) Data Element Requirements) for claims submitted without a HCPCS  code.   Claims for hepatitis B vaccinations must report the NPI number of the referring physician. In addition, if a doctor of medicine or osteopathy does not order the influenza virus vaccine, the MACs (Part A) claims require:    The providers own NPI to be reported in the NPI field for the attending physician.   10.2.2 - Claims Submitted to MACs Using Institutional Formats  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  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.