Flu Vaccine Coding and Billing Update
For the 2017-2018 influenza virus season, coders have two new CPT codes for reporting vaccines: 90682 and 90756.
CPT code 90682 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use is effective Aug. 1, 2017 through July 31, 2018, and has a payment allowance of $46.313.
CPT code 90756 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use is effective Jan. 1, 2018 through July 31, 2018, and will have a payment allowance of $22.793. Until this code goes into effect, the Centers for Medicare & Medicaid Services (CMS) instructs healthcare providers to report HCPCS Level II code Q2039 Influenza virus vaccine, not otherwise specified. The payment allowance for Q2039 is determined by local claims processing contractors.
Code also the administration (e.g., HCPCS Level II G0008 Administration of influenza virus vaccine).
Payment Allowance Limits
The payment allowance limits for influenza, pneumococcal, and hepatitis B vaccines are 95 percent of the average wholesale price (AWP), except when administered in the hospital outpatient department, where the vaccine is paid at reasonable cost. The payment allowance limits for drugs and biologicals that are not included in the Average Sales Price Medicare Part B Drug Pricing File or Not Otherwise Classified Pricing File are based on the published Wholesale Acquisition Cost (WAC) or invoice pricing, except under the Outpatient Prospective Payment System, where the payment allowance limit is 95 percent of the published AWP. The payment limit is 106 percent of the lesser of the lowest-priced brand or median generic WAC.
The 2017-2018 payment allowances and effective dates for all influenza vaccines are listed on the CMS website.
Part B Benefits
Medicare Part B covers both the costs and administration of influenza, pneumococcal polysaccaride, and hepatitis B immunizations.
The flu vaccine is generally an annual benefit (although, there are exceptions). There is no coinsurance or co-payment, and a beneficiary does not have to meet their deductible to receive this benefit.
Medicare covers one pneumonia vaccine per lifetime; however, Medicare will also cover a booster vaccine for high-risk individuals if five years have passed since the last vaccination. There is no coinsurance or co-payment, and a beneficiary does not have to meet their deductible to receive this benefit.
Individuals at high or intermediate risk for hepatitis B, such as those with renal disease or hemophilia, homosexual men, and clients of institutions for the mentally handicapped, are eligible to receive a hepatitis B vaccine. The coinsurance or co-payment applies after the yearly deductible has been met.
Other preventive vaccines, such as Tdap, are generally covered under Part D.
National Drug Codes
Naturally, the rules for National Drug Codes (NDCs) rely on the payer, be it commercial or federal. Be sure to check with your payer regarding how these changes affect your reporting of NDCs.
Update: See MLN Matters Number SE17026, released Sept. 21, 2017, for the latest 2017-2018 Influenza resources for healthcare professionals.