Issue 2006-03, March 2006

Guidelines for Payment of Vaccine (Pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus) Administration

Provider Types Affected
Hospitals, home health agencies (HHA), skilled nursing facilities (SNFs), critical access hospitals (CAH), provider-based renal dialysis facilities (RDF), comprehensive outpatient rehabilitation facilities (CORF), and freestanding RDF that bill Medicare fiscal intermediaries (FIs) for vaccine administration

Provider Action Needed

Impact to You
CR4240 clarifies and provides guidelines for Medicare FIs payment of vaccine administration and payment for these vaccines.

Special note: For claims with dates of service prior to January 1, 2006, Outpatient Prospective Payment System (OPPS) and non-OPPS hospitals report G0010 for Hepatitis B vaccine administration. For claims with dates of service January 1, 2006 and later, OPPS hospitals report 90471 or 90472 for Hepatitis B vaccine administration as appropriate in place of G0010.

What You Need to Know
Recognize the type of bill (TOB) and payment method, HCPCS codes, and their definitions for vaccine administration.

What You Need to Do
Use the appropriate TOB and HCPCS codes when billing for the vaccines using the information listed within this article.

Background
The Centers for Medicare & Medicaid Services (CMS) is clarifying its policy regarding payment for vaccine administration. This instruction clarifies and provides guidelines for the payment of vaccine administration in various institutional provider settings. In addition, CMS is updating payment for vaccines (Pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus) provided in Comprehensive Outpatient Rehabilitation Facilities (CORF) and Renal Dialysis Facilities (RDFs).

Section 10.2.2.1 of the Medicare Claims Processing Manual: “FI Payment for Pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus Vaccines and Their Administration” has been updated, and payment for the vaccines is as follows:

Payment for the Influenza Virus and PPV Vaccines

Payment for the Administration of Influenza Virus and PPV Vaccines

Guidelines for Pricing PPV and Influenza Virus Vaccine Administration under the MPFS

FIs make reimbursement based on the rate in the MPFS associated with the CPT code 90782 or 90471 as follows:

See the Medicare Claims Processing Manual, Chapter 18, Section 10.2.2.2, for information on payment to independent and provider based Rural Health Centers and Federally Qualified Health Clinics. That manual may be found at http://new.cms.hhs.gov/manuals/downloads/clm104c18.pdf on the CMS Web site.

Payment for the administration of Hepatitis B Virus vaccine is as follows:

Guidelines for Pricing Hepatitis B Virus Vaccine Administration under the MPFS

FIs will make reimbursement based on the rate in the MPFS associated with the CPT code 90782 or 90471 as follows:

See the Medicare Claims Processing Manual, Chapter 18, section 10.2.2.2 for payment to independent and provider-based Rural Health Centers and Federally Qualified Health Clinics. That manual may be found at http://new.cms.hhs.gov/manuals/downloads/clm104c18.pdf on the CMS Web site.

Implementation
The implementation date for this instruction is July 3, 2006.

Additional Information
The revised portions of the Medicare Claims Processing Manual are attached to CR4240, which is the official instruction issued to your intermediary regarding this change. That instruction can be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R844CP.pdf on the CMS Web site.

If you have questions, please contact your intermediary at their toll-free number which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article 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. 100-4, Transmittal# R844CP, CR# 4240
Medlearn Matters Number: MM4240
Related CR Release Date: February 10, 2006
Effective Date: July 1, 2006
Implementation Date: July 3, 2006