(Medicare Claims Processing Manual)

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   MACs (Part B) use specialty code 60 (Public Health or Welfare Agencies (Federal, State, and Local)) for Public Health Service Clinics (PHCs).   MACs (Part B) use specialty code 73 (Mass Immunization Roster Billers) for specialty code C1 centralized billers and specialty code A5 for pharmacies (all other suppliers (drug stores, department stores)).   Entities and individuals other than PHCs and pharmacies use the CMS specialty code that best defines their provider type.  A list of specialty codes can be found in Pub. 100- 04, Chapter 26.  The CMS specialty code 99 (Unknown Physician Specialty) is accept able where no other code fits.   Place of Service (POS)   State or local PHCs use POS code 71 (State or Local Public Health Clinic).  POS 71 is not used for individual offices/entities other than PHCs (e.g., a mobile unit that is non- PHC affiliated should use POS 99).  Preprinted Form CMS -1500s (08- 05) used for simplified roster billing should show POS 60 (Mass Immunization Center) regardless of the site where vaccines are given (e.g., a PHC or physicians office that roster claims should use POS 60).  Individuals/entities administering influenza virus, pneumococcal, and COVID -19 vaccinations in a mass immunization setting (including centralized billers), regardless of th e site where vaccines are given, should use POS 60 for roster claims, paper claims, and electronically filed claims.   Normal POS codes should be used in other situations.  Providers use POS 99 (Other Unlisted Facility) if no other POS code applies.  10.2.5.1 -  MAC (Part B) Indicators for the Common Working File (CWF)                     (Rev. 11362; Issued: 04 -22-22; Effective: 01 -11-22; Implementation:07 -05-22)  The MAC (Part B) record submitted to CWF must contain the following indicators:   Description  Payment Indicator  Payment  Deductible Indicator  Deductible  Type of Service  Pneumococcal  1 100 percent  1 Zero deductible  V Influenza  1 100 percent  1 Zero deductible  V Hepatitis B  1 100 percent  1 Zero deductible  "9" COVID- 19 1 100 percent  1 Zero  deductible  V  A payment indicator of 1 represents 100 percent payment.  A deductible indicator of 1 represents a zero deductible.  A payment indicator of 0 represents 80 percent payment.  A deductible indicator of 0 indicates that a deductible applies to the cla im.  The record must also contain a V in the type of service field, which indicates that this is a pneumococcal, influenza virus, or COVID -19 vaccine.  MACs (Part B) use a 1 in the type of service field, which indicates medical care for a hepatitis B vaccin e.  10.2.5.2 - MAC (Part B) Payment Requirements                                                                                           (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)                                     Payment for Medicare covered preventive vaccines, including the recently developed COVID -19 vaccines, follows the same standard rules that are applicable to any injectable drug or biological.    Effective for claims with dates of service on or after February 1, 2001, 114, of the Benefits Improvement and Protection Act of 2000 mandated that all drugs and biologicals be paid based on mandatory assignment.  Therefore, all providers of Medicare cover ed preventive vaccines, must accept assignment for the vaccine.   Prior to March 1, 2003, the administration of pneumococcal, influenza virus, and hepatitis B vaccines, (HCPCS codes G0008, G0009, and G0010), though not reimbursed directly through the MPFS, were paid at the same rate as HCPCS code 90782 on the MPFS for the year that corresponded to the date of service of the claim.    For dates of service on or after March 1, 2003 through December 31, 2021, payment rates for HCPCS G0008, G0009, and G0010 were paid at the same rate as similar services on the MPFS determined through notice -and-comment rulemaking. These payment amounts wer e determined on an annual basis and MACs were notified accordingly.  Beginning January 1, 2022, the national payment rate for HCPCS G0008, G0009, and G0010 is $30.  This payment amount is adjusted based on the Geographic Practice Cost Indices used in the MPFS.  Locality -adjusted payment rates for HCPCS G0008, G0009, and G0010 are available of the CMS website: https://www.cms.gov/Medicare/Medicare -Fee-for-Service -Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing        Beginning January 1, 2022 and through the end of the calendar year in which the PHE for COVID -19 ends, the national payment rate for the administration of COVID -19 vaccines is $40.  This payment amount is adjusted based on the Geographic Practice Cost Indi ces used in the MPFS.  Locality -adjusted payment rates for the administration of COVID -19 vaccines are available of the CMS website: https://www.cms.gov/medicare/medicare -part-b-drug- average- sales -price/covid -19-vaccines -and-monoclonal -antibodies   Effective January 1 of the year following the year in which the PHE for COVID -19 ends, the payment rate for COVID -19 vaccine administration will be set at a rate to align with the payment rate for the administration of other Part B preventive vaccines.   Assignment for the administration is not mandatory, but is applicable should the provider be enrolled as a provider type Mass Immunization Roster Biller, submits roster bills, or participates in the centralized billing program.   MACs (Part B) may not apply the limiting charge provision for pneumococcal, influenza virus , hepatitis B, or COVID -19 vaccines and their administration in accordance with 1833(a)(1)  and 1833(a)(10)(A) of the Social Security Act (the Act.)    The vaccine and administration of the pneumococcal and influenza virus, and COVID -19 vaccine is covered in 1861(s)(10)(A)  of the Act; 1861(s)(10)(B) includes the hepatitis B vaccine and administration rather than under the physicians services benefit.  Therefore, it is not eligible for the 10 percent Health Professional Shortage Area (HPSA) incentive payment or the 5 perce nt Physician Scarcity Area (PSA) incentive payment.     No Legal Obligation to Pay  Nongovernmental entities that provide immunizations free of charge to all patients, regardless of their ability to pay, must provide the immunizations free of charge to Medicare beneficiaries and may not bill Medicare.  (See Pub. 100- 02, Medicare Benefit P olicy Manual, chapter 16.)  Thus, for example, Medicare may not pay for influenza virus vaccinations administered to Medicare beneficiaries if a physician provides free vaccinations to all non -Medicare patients or where an employer offers free vaccinations  to its employees.  Physicians also may not charge Medicare beneficiaries more for a vaccine than they would charge non -Medicare patients.  (See 1128(b)(6)(A)  of the Act.)  When an employer offers free vaccinations to its employees, it must also offer the free vaccination to an employee who is also a Medicare beneficiary.  It does not have to offer free vaccinations to its non- Medicare employees.   Nongovernmental entities that do not charge patients who are unable to pay or reduce their charges for patients of limited means, yet expect to be paid if the patient has health insurance coverage for the services provided, may bill Medicare and expect payment.   Governmental entities (such as PHCs) may bill Medicare for pneumococcal, hepatitis B, influenza virus, and COVID -19 vaccines administered to Medicare beneficiaries when services are rendered free of charge to non- Medicare beneficiaries. Government entities  may NOT bill Medicare for vaccine products during a public health emergency when vaccines are provided at no charge to Medicare and non -Medicare beneficiaries.   10.3 - Simplified Roster Claims for Mass Immunizers (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  The simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass pneumococcal and influenza vaccination programs offered by PHCs and other individuals and entities that give the vaccine to a group of beneficiaries , e.g. at PHCs, shopping malls, grocery stores, senior citizen homes, and health fairs. Effective December 11, 2020 roster billing is also available for billing COVID -19 vaccinations.   Roster billing is not available for hepatitis B vaccinations.    If they agree to accept assignment for these claims, properly licensed individuals and entities conducting mass immunization programs may submit claims using a simplified claims filing procedure known as roster billing to bill for influenza virus, pneumoc occal or COVID -19 vaccinations for multiple beneficiaries.  They may not collect any payment from the beneficiary.     Entities that submit claims on roster claims must accept assignment and may not collect any donation or other cost sharing of any kind from Medicare beneficiaries for pneumococcal, influenza virus, or COVID -19 vaccinations.  However, the entity may bill Medicare for the amount, which is not subsidized from its own budget.  For example, an entity that incurs a cost of $7.50 per vaccination and pays $2.50 of the cost from its budget may bill Medicare the $5.00 cost which is not paid out of its budget.  A. Provider Enrollment Criteria for Mass Immunizers   Those entities and individuals that desire to provide mass immunization services, but may not otherwise be able to qualify as a Medicare provider, may be eligible to enroll as a provider type Mass Immunization Roster Biller.   These individuals and entities must enroll by completing the Provider/Supplier Enrollment Application, Form CMS -855.  Individuals and entities that enroll as this provider type may not bill Medicare for any services other than pneumococcal, influenza virus , and/or COVID -19 vaccines and their administration.  In addition, claims submitted by the provider type Mass Immunization Roster Biller are always reimbursed at the assigned payment rate.   B. Payment Floor for Roster Claims   Roster claims are considered paper claims and are not paid as quickly as electronic media claims (EMC).  If available, offer electronic billing software free or at -cost to PHCs and other properly licensed individuals and entities.  MACs (Part B) must ensur e that the software is as user friendly as possible for the pneumococcal, influenza virus and COVID -19 vaccination billing.   10.3.1 -  Roster Claims Submitted to A/B MACs (B) for Mass Immunization Roster Claims Submitted to AB MACs (B) for Mass Immunization  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  If the PHC or other individual or entity qualifies to submit roster claims, it may use a preprinted Form CMS -1500 that contains standardized information about the entity and the benefit.  See Pub. 100-04, Chapter 26, 10 for more information about the CMS -1500 claim form.  Key information from the beneficiary roster list and the abbreviated claim form is used to process pneumococcal, influenza, and COVID -19 vaccination claims.   Separate CMS -1500 claim forms, along with separate roster bills, must be submitted for influenza virus, pneumococcal, and COVID -19 roster billing.  If other services are furnished to a beneficiary along with pneumococcal, influenza, or COVID -19 vaccines, individuals and entities must submit claims using normal billing procedures, e.g., submission of a separate claim for each beneficiary.