New Codes, Fees for Flu Shots

You now have five new HCPCS Level II codes to report to Medicare during the 2010-2011 influenza season, and reimbursement is going up for some immunizations. New Q codes replace CPT® code 90658, which describes the regular adult dose vaccine that is supplied in a multi-dose vial. The change was necessary, according to the Centers for Medicare & Medicaid Services (CMS), to create separate billing codes for each brand name vaccine product included in 90658.

Providers may continue to report CPT® code 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use until Dec. 31.

After that, Medicare will no longer reimburse CPT® code 90658, and providers must use the following Q codes to report the same service:

HCPCS Code Long Description
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)

Pump Up Your Payments

Providers who hold seasonal flu claims for Fluvirin and Fluzone until the corresponding Q codes go into effect Jan. 1, 2011 may stand to gain financially. 

Effective Sept. 1 to Dec. 31, the Medicare Part B payment limit for 90658 is $11.368. Whereas, effective for service dates on or after Oct. 1, the Medicare Part B payment allowance for Q2036 is $7.439, for Q2037 is $13.253, and for Q2038 is $12.593. (National payment limits for Q2035 and Q2039 are determined by your local claims processing contractor.)

The 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 (PPS) under Medicare. For example, where the vaccine is furnished in the hospital outpatient department, rural health clinic (RHC), or federally qualified health center (FQHC), payment for the vaccine is based on reasonable cost.

Annual Part B deductible and coinsurance amounts do not apply.

CMS Corrects Payment Limit for 90655

Providers also should be aware that, effective for service dates on or after Sept. 1, the Medicare Part B payment limit for CPT® 90655 Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use is $14.858. This is a correction to Transmittal 2071, Change Request 7120, dated Oct. 22, which listed an incorrect payment limit of $12.398.

Source: CMS Transmittal 815, Change Request 7234, issued Nov. 19

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6 Responses to “New Codes, Fees for Flu Shots”

  1. Pam says:

    Should we use these Q codes for flu shots for ALL payers or just Medicare?

  2. Ursula Funk says:

    All the codes for change for everyone.

  3. Ursula Funk says:

    Correction, all payers should change to the Q codes.

  4. lesia Johnson says:

    Will the adminstration code 90471 still be used with the new Qcodes?

  5. helen parise says:

    WOULD ADMINISTRATION CODE STILL BE G0008, WITH Q CODES ?

  6. Ravinder says:

    We will have to continue using G codes as administration codes as earlier.

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