evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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:
(Medicare Claims Processing Manual)
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:
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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