Payment Amounts for the Influenza Virus Vaccine (CPT 90658) and the Pneumococcal Vaccine (CPT 90732) When Payment Is Based on 95 Percent of the Average Wholesale Price (AWP)

Provider Types Affected
Physicians, non-physician practitioners, providers, and suppliers

Provider Action Needed

Impact to You
Effective September 1, 2004, the Medicare Part B payment allowance for the Influenza Virus Vaccine [CPT 90658] is $10.10 and for the Pneumococcal Vaccine [CPT 90732] is $23.28 (when payment is based on 95 percent of the AWP).

What You Need to Know
Annual Part B deductible and coinsurance amounts do not apply.

What You Need to Do
Please take note of this pricing information to ensure accurate claims processing. Your carrier or fiscal intermediary will not search their files to adjust claims that were processed prior to the October 1, 2004 implementation date unless you bring such claims to their attention.

Additional Information
The official instruction issued regarding this change can be found online, referenced via CR 3490, at: http://www.cms.hhs.gov/Transmittals/ .

On the above online page, scroll down while referring to the CR column on the right to find the link for CR 3490. Click on the link to open and view the file for the CR.

If you have questions regarding this issue, you may also contact your carrier or fiscal intermediary on their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf.

Disclaimer
Medlearn Matters articles are prepared as a service to the public and are not intended to grant rights or impose obligations. Medlearn Matters articles 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.

For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles/.

Pub. 100-20, Transmittal #114, CR # 3490
Medlearn Matters Number: MM3490

Effective Date: September 1, 2004
Implementation Date: October 1, 2004

Additional Information Provided by Empire Medicare Services

Billing Instructions and Fees for Influenza and Pneumococcal Vaccines in 2004-2005
Vaccines and administration codes are paid at 100 percent of the amounts listed below, and the allowance for the vaccines is the same for all areas. The vaccine fees are effective for dates of service September 1, 2004 and forward. The annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners, and suppliers who administer these vaccines must take assignment on the claims for the vaccines. The appropriate ICD-9-CM code for the influenza vaccine is V04.81. The appropriate ICD-9-CM code for the pneumococcal vaccine is V03.82.

The administration codes for both vaccines are not bundled into any Evaluation and Management (visit) codes. If an eligible visit is rendered in addition to the vaccine(s) and its administration, all services may be considered for reimbursement. The modifier 25 does not need to be added to the Evaluation and Management service. However, if the sole purpose of the patient’s visit is to receive one or both of these vaccines, a charge should not be made for even a low-level office visit.

New Jersey localities:
Locality 01 Bergen, Essex, Hudson, Hunterdon, Middlesex, Morris, Passaic, Somerset, Sussex, Union and Warren
Locality 99 Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Monmouth, Ocean and Salem

New York localities:
Locality 01 Manhattan
Locality 02 Bronx/Brooklyn/Nassau/Staten Island/Suffolk/Westchester/Rockland
Locality 03 Columbia/Delaware/Dutchess/Greene/Orange/Putnam/Sullivan/Ulster