by Jared Staheli
June 25th, 2015
A. Edits Not Applicable to Pneumococcal or Influenza Virus Vaccine Bills and Their Administration
The Common Working File (CWF) and shared systems bypass all Medicare Secondary Payer (MSP) utilization edits in CWF on all claims when the only service provided is pneumococcal or influenza virus vaccine and/or their administration. This waiver does not apply when other services (e.g., office visits) are billed on the same claim as pneumococcal or influenza virus vaccinations. If the provider knows or has reason to believe that a particular group health plan covers pneumococcal or influenza virus vaccine and their administration, 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 pneumococcal or influenza virus vaccines. However, first claim development is performed if other services are submitted along with pneumococcal or development is performed if other services are submitted along with pneumococcal or influenza virus vaccines.
See Pub. 100-05, Medicare Secondary Payer Manual, chapters 4 and 5, for responsibilities for MSP development where applicable.
B. Fiscal Intermediary (FI)/AB MAC Bills
Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to FIs/AB MACs.
The following “providers of services” may administer and bill the FI/AB MACs for these vaccines:
• Critical Access Hospitals (CAHs);
• Skilled Nursing Facilities (SNFs);
• Home Health Agencies (HHAs);
• Comprehensive Outpatient Rehabilitation Facilities (CORFs); and
• Indian Health Service (IHS)/Tribally owned and/or operated hospitals and hospital-based facilities. Other billing entities that may bill the FIs/AB MACs are:
• Independent Renal Dialysis Facilities (RDFs).
All providers bill the FIs/AB MACs for hepatitis B on Form CMS-1450. Providers other than independent RHCs and freestanding FQHCs bill the FIs/AB MACs for influenza virus and pneumococcal vaccinations on Form CMS-1450. (See §10.2.2.2 of this chapter for special instructions for independent RHCs and freestanding FQHCs and §10.2.4 of this chapter for hospice instruction.)
FIs/AB MACs instruct providers, other than independent RHCs and freestanding FQHCs, to bill for the vaccines and their administration on the same bill. Separate bills for vaccines and their administration are not required. The only exceptions to this rule occur when the vaccine is administered during the course of an otherwise covered home health visit since the vaccine or its administration is not included in the visit charge. (See §10.2.3 of this chapter).
C. Carrier/AB MAC Claims
1. Billing for Additional Services
If a physician sees a beneficiary for the sole purpose of administering the influenza virus vaccine, the pneumococcal vaccine, and/or the hepatitis B vaccine, they may not routinely bill for an office visit. However, if the beneficiary actually receives other services constituting an “office visit” level of service, the physician may bill for a visit in addition to the vaccines and their administration, and Medicare will pay for the visit in addition to the vaccines and their administration if it is reasonable and medically necessary.
2. Nonparticipating Physicians and Suppliers
Nonparticipating physicians and suppliers (including local health facilities) that do not accept assignment may collect payment from the beneficiary for the administration of the vaccines, but must submit an unassigned claim on the beneficiary’s behalf. Effective for claims with dates of service on or after February 1, 2001, per §114 of the Benefits Improvement and Protection Act of 2000, all drugs and biologicals must be paid based on mandatory assignment. Therefore, regardless of whether the physician and supplier usually accept assignment, they must accept assignment for the vaccines, may not collect any fee up front, and must submit the claim for the beneficiary.
Entities, such as local health facilities, that have never submitted Medicare claims must obtain a National Provider Identifier (NPI) for Part B billing purposes.
3. Separate Claims for Vaccine and Their Administration
In situations in which the vaccine and the administration are furnished by two different entities, the entities should submit separate claims. For example, a supplier (e.g., a pharmacist) may bill separately for the vaccine, using the Healthcare Common Procedural Coding System (HCPCS) code for the vaccine, and the physician or supplier (e.g., a drugstore) who actually administers the vaccine may bill separately for the administration, using the HCPCS code for the administration. This procedure results in contractors receiving two claims, one for the vaccine and one for its administration.
For example, when billing for influenza virus vaccine administration only, billers should list only HCPCS code G0008 in block 24D of the Form CMS-1500. When billing for the influenza virus vaccine only, billers should list only HCPCS code 90658 in block 24D of the Form CMS-1500. The same applies for pneumococcal and hepatitis B billing using pneumococcal and hepatitis B HCPCS codes.