DM Quality Consulting, LLC

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1 DM Quality Consulting, LLC Providing an honest, compliant, quality service Billing Guidelines for Influenza, Pneumonia And Hepatitis B Vaccines for Indian Health Facilities Vaccines (pneumococcal pneumonia, influenza virus and hepatitis B virus) and their administration provided by Indian Health Service (IHS)/tribally owned and/or operated hospitals and hospital-based facilities will be paid in addition to the All-Inclusive Rate (AIR) or facility-specific rate for Critical Access Hospitals (CAHs). Medicare does not require, for coverage purposes, that a doctor of medicine or osteopathy order these vaccines (influenza and pneumonia only). Therefore, the beneficiary may receive these vaccines upon request without a physician's order and without physician supervision. Influenza Immunizations Medicare covers both the costs of the vaccine and its administration by recognized providers. There is no coinsurance or co-payment applied to this benefit, and a beneficiary does not have to meet his or her deductible to receive this benefit. Pneumococcal Polysaccharide Vaccinations Medicare provides coverage for 1 pneumococcal polysaccharide vaccine for all beneficiaries. One vaccine at age 65 generally provides coverage for a lifetime, but for some high risk persons, a booster vaccine is needed. Medicare will also cover a booster vaccine for high risk persons if 5 years have passed since the last vaccination. Medicare covers both the costs of the vaccine and its administration by recognized providers. There is no coinsurance or copayment applied to this benefit, and a beneficiary does not have to meet his or her deductible to receive this benefit. Hepatitis B Vaccine Medicare covers the hepatitis B vaccine for certain beneficiaries who are at intermediate to high risk for the hepatitis B virus (HBV). These individuals include workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work, those with End-Stage Renal Disease (ESRD), persons who live in the same household as an HBV carrier, and persons diagnosed with diabetes mellitus. The Hepatitis B vaccine requires an order from a physician. DISCLAIMER - The information in these publications are provided "as is" without any expressed or implied warranty. While all information in these documents are believed to be correct at the time of writing, these documents are for educational purposes only and do not purport to provide legal or medical advice. It is the provider's responsibility to stay current with CMS and the Medicare Administrative Contractor's (MAC) guidelines. CPT codes, descriptors, and other data only are copyright 2013 American Medical Association. All rights reserved, Applicable FARS/DFARS apply. Published June 2014 DM

2 Vaccine HCPCS INFLUENZA VACCINES Flu vaccine, adjuvant, im Flu vaccine, intradermal, no preserv Flu vaccine, trivalent, no preserv 6 35m Flu vaccine, trivalent, no preserv 3 & > Flu vaccine, trivalent, 6 35 mo, im Flu vaccine, trivalent, nasal (FluMist ) Flu vaccine, preserv & antibiotic free, im Flu vaccine, nasal (Fluzone ) Flu vaccine, nasal admin Flu vaccine, Recombinant Himagglutinin antigen, im, (Flublok) effect Flu vaccine, quadrivalent, split virus, no preserv 6-35m Flu vaccine, quadrivalent, split virus, no preserv 3 yrs & > Flu vaccine, quadrivalent, split virus, 6-35m Flu vaccine, quadrivalent, split virus, 3 yrs & > Q2033 Flu vaccine, recombinant hemagglutinin antigen, im, (Flublok) 7/1/13 to 12/31/13 Q2034 Agriful vacc, 3 yrs & >, im Q2035 Afluria vacc, 3 yrs & >, im Q2036 Flulaval vacc, 3 yrs & >, im Q2037 Fluvirin vacc, 3 yrs & >, im Q2038 Fluzon vacc, 3 yrs & >, im Q2039 NOS flu vacc, 3 yrs & > im PNEUMOCOCCAL VACCINE Pneumococcal vacc, 7 valent, im Pneumococcal vacc, 13 valent, im Pneumococcal vaccine HEPATITIS VACCINE Hep B vacc, adult 2 dose, im Hep B vacc, ill pat 3 dose im Hep B vacc, adol, 2 dose, im Hep B vacc ped/adol 3 dose im Hep B vaccine, adult, im Hep B vacc, ill pat 4 dose im Page 2 of 9

3 Administration G0008 Administration of influenza virus vaccine G0009 Administration of pneumococcal vaccine G0010 Administration of hepatitis B vaccine Diagnosis Codes for DOS Prior to Oct. 1, 2015 V0481 V0382 V053 Influenza virus vaccine Pneumococcal vaccine Hepatitis B vaccine V06.6 Both pneumococcal vaccine and influenza vaccine For DOS October 1, 2015 and after use ICD-10 diagnosis Z23. Part A Outpatient hospitals, provider-based clinics submit these vaccines on a UB-04 claim form to Medicare Part A. There will not be a separate Part B claim, unless the patient had a medically necessary visit with a physician or non-physician practitioner on the same day. If the only reason for the visit was to receive the flu or pneumonia vaccine, do not bill a 0510 revenue code. Note: These vaccines and their administration, when rendered during a medically necessary visit for a medical condition, should be included on the same claim. Condition code A6 is required for the pneumococcal pneumonia and influenza vaccines. Revenue Codes 0636 Pharmacy, drugs requiring detailed coding 0771 Preventive care services, vaccine administration Revenue Code (FL 42) HCPCS (FL 44) Charge (FL 47) Date of Service (FL 45) $ /10/ G0008 $ /10/ $ /10/ $ Page 3 of 9

4 Part B Free-standing clinics submit vaccines on the CMS-1500 claim form. Roster Billing Part A IHS/tribal hospitals and their provider-based clinics that provide mass immunization services, whether in the hospital/clinic or at local sites (e.g., chapter house, schools), can submit a roster bill to Part A through DDE. You can submit roster bills electronically or via paper. However, Medicare-covered vaccinations are exempt from the Health Insurance Portability and Accountability Act (HIPAA) electronic billing requirement. Page 4 of 9

5 The RECEIPT DATE is system generated and only one date of service per Roster Bill is acceptable. A maximum of ten (10) patients per page may be reported on a Direct Data Entry (DDE) Roster page. The following fields must be completed on the Roster Bill Screen: Date of Service Type of Bill National Provider Identifier (NPI) Facility Zip Code Revenue Code, Healthcare Common Procedure Coding (HCPC), Charges per beneficiary HIC Number, Last Name, Middle Initial Birth Date Sex Admission date Admission type Admission diagnosis Patient status Admission source Press <F9> to store the Roster Bill into FISS. If the information is accepted, the message RECORD SUCCESSFULLY ADDED will be displayed. If there are errors, reason codes will appear at the bottom left of the screen. Press <F1> to review the first reason code. Press <F3> to return to the roster bill screen. Correct the errors and press <F9> to store the claim. Page 5 of 9

6 Part B Freestanding clinics (no hospital affiliation) that provide these same services must submit the roster bill to Part B on the CMS-1500 claim form and attach a copy of the patient roster form. The form must contain the following information: Provider s name and NPI number; Date of service; Control number; Beneficiary s Health Insurance Claim Number (HICN); Beneficiary s name; Beneficiary s address; Beneficiary s date of birth; Beneficiary s sex; and Beneficiary s signature or stamped signature on file. NOTE: A stamped signature on file qualifies as an actual signature on a roster claim form if you have a signed authorization on file to bill Medicare for services you provided. In this situation, you may report signature on file instead of obtaining the beneficiary s actual signature. NOTE: The roster bills for the influenza virus and pneumococcal vaccinations are not identical. Pneumococcal rosters must contain the following language: WARNING: Beneficiaries must be asked if they have received a pneumococcal vaccination. Rely on patients memory to determine prior vaccination status; If patients are uncertain whether they have been vaccinated within the past 5 years, administer the vaccine; and If patients are certain that they have been vaccinated within the past 5 years, do not revaccinate. The following fields must be completed on the CMS-1500 claim form: Item 1 Check Medicare box Item 2 Enter SEE ATTACHED ROSTER Item 11 Enter NONE Item 20 Enter X in the NO block Item 21 Enter V0481 for influenza or V0382 for pneumonia vaccine Item 24B Line 1 and line 2: Enter 60 (NOTE: POS code 60 is for roster billing) Item 24D Line 1: Select appropriate influenza or pneumonia vaccine HCPCS Line 2: Select appropriate administration code (G0008 or G0009) Item 24E Lines 1 and 2: Diagnosis pointer of 1 Item 24F Enter the charge for each listed service, not the total for all patients Item 27 Enter X in the YES block Item 29 Enter $0.00 Page 6 of 9

7 Item 31 Facility representative must sign Item 32 Name, address and zip of service location Item 32A NPI of service facility Item 33 Name, address and zip of billing provider Item 33A NPI of billing provider Refer to the Medicare Administrative Contractor s (MAC) web site for address to submit roster claims. Patient Roster Forms Page 7 of 9

8 Correcting Reason Code Part A claims will RTP (reject) if condition code A6 is not submitted for influenza or pneumonia vaccines. RTP 32200: Diagnosis V0481, V0382, or V066 is present on the claim and the claim does not contain condition code A6. From the Claims Correction menu in DDE, select 23 and ENTER. On MAP1741 enter the NPI, Beneficiary HIC and date of service. Under the SEL column put an S next to the claim that needs correction. On claim page 1 enter A6 in the COND CODES field. If the vaccine was not administered, then remove the V diagnosis on claim page 3. Press F9 to resend the claim. Page 8 of 9

9 Resources CMS Influenza, Pneumonia and Hepatitis B Quick Reference Guide MLN/MLNProducts/downloads/qr_immun_bill.pdf CMS Roster Billing Fact Sheet MLN/MLNProducts/downloads/Mass_Immunize_Roster_Bill_factsheet_ICN pdf Page 9 of 9