Flu Vaccine Q Code Undergoes Price Revision

On April 22, the Centers for Medicare & Medicaid Services (CMS) released Transmittal 884 to clarify payment for HCPCS Level II Q codes describing 2010-2011 seasonal influenza vaccines.

For dates of service on or after Jan. 1, 2011, Medicare will no longer accepts CPT® code 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use. Instead, “in response to a program need to establish separate billing codes for each brand-name influenza vaccine product,” CMS has designated five HCPCS Level II Q codes to describe influenza vaccines administered to individuals three years of age and older:

Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)

Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)

Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)

Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)

Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)

The above HCPCS Level II codes may be submitted with only those diagnosis codes previously allowable with CPT® 90658. All edits associated with 90658 apply to Q2035, Q2036, Q2037, Q2038, and Q2039.

Transmittal 884 repeats information initially released in Transmittal 815 (Nov. 2010)—with one important exception. Transmittal 884 updates the payment rate for Q2036 to $8.784. Payment for Q2037 does not change, at $13.253, while payment for Q2038 remains $12.593. No national payment limits are available for Q2035 and Q2039; rather, payment limits will be determined by the local claims processing contractor.

Per Transmittal 884, Medicare Part B payment limits for influenza vaccines are 95 percent of the average wholesale price (AWP), as reflected in the published compendia except where the vaccine is furnished in a setting that follows a cost-based or prospective payment system under Medicare. (e.g., where the vaccine is furnished in the hospital outpatient department, rural health clinic, or federally qualified health center, payment for the vaccine is based on reasonable cost). Annual Part B deductible and coinsurance amounts do not apply to Q2035, Q2036, Q2037, Q2038, and Q2039.

Source: CMS Transmittal 884, Change Request (CR) 7234, issued April 22, 2011.

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2 Responses to “Flu Vaccine Q Code Undergoes Price Revision”

  1. Stephanie says:

    Has any one heard/read if the commercial carriers are paying the Q2034-Q2039 or are we supposed to still be coding the 9xxxx series codes?

    I’m having a hard time locating any firm documentation in various news letters.

    Thanks

  2. rajesh says:

    thank you its so useful

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