MIR-2006-8A, August 2006

Billing Instructions for Influenza, Pneumococcal and Hepatitis B Vaccine

The Medicare program covers Influenza, Pneumococcal Polysaccharide, and Hepatitis B vaccines and their administration when they are furnished to eligible beneficiaries in accordance with coverage rules. The beneficiary may receive the influenza and PPV vaccine upon request without a physician’s order and without physician supervision. Part B deductible and coinsurance do not apply for PPV and influenza virus vaccine. The Hepatitis B vaccine and its administration are covered if ordered by a doctor of medicine or osteopathy. Part B deductible and coinsurance will be applied to claims for Hepatitis B vaccine. Reimbursement for all of these vaccines is on a reasonable-cost basis for hospitals, skilled nursing facilities (SNFs), critical access hospitals (CAHs), and hospital-based renal dialysis facilities (RDFs). Payment for comprehensive outpatient rehabilitation facilities (CORFs) and independent RDFs is based on 95 percent of the average wholesale price (AWP).

When vaccines are provided to inpatients of a hospital or skilled nursing facility (SNF), it is covered under the vaccine benefit. However, the hospital bills the fiscal intermediary (FI) on bill type 12X using the discharge date of the hospital stay or the date benefits are exhausted. A SNF submits type of bill 22X for its Part A inpatients.

HCPCS Coding

Influenza Virus Vaccine:

Pneumococcal Polysaccharide Vaccine:

Hepatitis B Vaccine:

*Note: For claims with dates of service prior to January 1, 2006, OPPS and non-OPPS hospitals report G0010 for Hepatitis B vaccine administration. For claims with dates of service of January 1, 2006 and later, OPPS hospitals report 90471 or 90472 for Hepatitis B vaccine administration as appropriate in place of G0010.

Diagnosis Code :

*Note: Effective October 1, 2006, providers may report diagnosis code V06.6 on claims for influenza virus and/or PPV when the purpose of the visit was to receive both vaccines.

Revenue Code :

Bill Type :

Roster Billing
Roster billing is a streamlined process for submitting health care claims for large groups of individuals usually for influenza and/or PPV vaccinations for which Health Insurance Portability and Accountability Act of 1996 (HIPAA) adopted an electronic standard, the ASC X12N 837. Generally, for institutional claims (Part A claims submitted to Medicare fiscal intermediaries for processing) only, providers must vaccinate at least five beneficiaries per day to roster bill.

Effective July 3, 2006, the discharge date is no longer required for inpatient Part B (bill types 12X and 22X) roster claims. However, providers must continue to enter the following data elements that were required on inpatient Part B roster bills effective October 1, 2005:

1. Admission date
2. Admission type
3. Admission diagnosis
4. Admission source code
5. Patient status code

Condition codes A6 and M1 will appear on roster bills for influenza and PPV in Form Locators 24-30. Medicare Secondary Payer (MSP) utilization editing is bypassed in the Common Working File (CWF) for all mass immunizer roster bills. However, if the provider knows that a particular group health plan covers the PPV and all other MSP requirements for the Medicare beneficiary are met, the primary payer must be billed. First claim development alerts from CWF are not generated for PPV and influenza virus vaccines.