by Jared Staheli
June 25th, 2015
Some potential "mass immunizers," such as hospital outpatient departments and HHAs, have expressed concern about the complexity of billing for the influenza virus vaccine and its administration. Consequently, to increase the number of beneficiaries who obtain needed preventive immunizations, simplified (roster) billing procedures are available to mass immunizers. The simplified (roster) claims filing procedure has been expanded for the pneumococcal vaccine. A mass immunizer is defined as any entity that gives the influenza virus vaccine or pneumococcal vaccine to a group of beneficiaries, e.g., at public health clinics, shopping malls, grocery stores, senior citizen homes, and health fairs. To qualify for roster billing, immunizations of at least five beneficiaries on the same date are required. (See §10.3.2.2 for an exception to this requirement for inpatient hospitals.)
The simplified (roster) claims filing procedure applies to providers other than RHCs and FQHCs that conduct mass immunizations. Since independent and provider based RHCs and FQHCs do not submit individual Form CMS-1450s for the influenza virus vaccine, they do not utilize the simplified billing process. Instead, payment is made for the vaccine at the time of cost settlement.
The simplified process involves use of the provider billing form (Form CMS-1450) with preprinted standardized information relative to the provider and the benefit. Mass immunizers attach a standard roster to a single pre-printed Form CMS-1450 that contains the variable claims information regarding the service provider and individual beneficiaries.
Qualifying individuals and entities must attach a roster, which contains the variable claims information regarding the supplier of the service and individual beneficiaries.
The roster must contain at a minimum the following information:
• Provider name and number;
• Date of service;
• Patient name and address;
• Patient date of birth;
• Patient sex;
• Patient health insurance claim number; and
• Beneficiary signature or stamped "signature on file."
In addition, for inpatient Part B services (12x and 22X) the following data elements are also needed:
• Admission date;
• Admission type;
• Admission diagnosis;
• Admission source code; and
• Patient status code.
NOTE: A stamped "signature on file" can be used in place of the beneficiary's actual signature for all institutional providers that roster bill from an inpatient or outpatient department provided the provider has a signed authorization on file to bill Medicare for services rendered. In this situation, they are not required to obtain the patient signature on the roster.
However, the provider has the option of reporting "signature on file" in lieu of obtaining the patient's actual signature on the roster. The pneumococcal vaccine roster must contain the following language to be used by providers as a precaution to alert beneficiaries prior to administering the pneumococcal vaccine.
Warning: Beneficiaries must be asked if they have been vaccinated with the pneumococcal vaccine.
• Rely on the patients' memory to determine prior vaccination status.
• If patients are uncertain whether they have been vaccinated within the past 5 years, administer the vaccine,
• If patients are certain that they have been vaccinated within the past 5 years, do not revaccinate.
For providers using the simplified billing procedure, the modified Form CMS-1450 shows the following preprinted information in the specific form locators (FLs). Information regarding the form locator numbers that correspond to the data element names below and a table to crosswalk the CMS-1450 form locators to the 837 transaction is found in chapter 25:
• The words "See Attached Roster" (Patient Name);
• Patient Status code 01 (Patient Status);
• Condition code M1 (Condition Code) (See NOTE below);
• Condition code A6 (Condition Code);
• Revenue code 636 (Revenue Code), along with the appropriate HCPCS code in FL 44 (HCPCS Code);
• Revenue code 771 (Revenue Code), along with the appropriate "G" HCPCS code (HCPCS Code);
• "Medicare" (Payer, line A);
• The words "See Attached Roster" (Provider Number, line A); and
• Diagnosis code V03.82 for the pneumococcal vaccine or V04.8 for Influenza Virus vaccine (Principal Diagnosis Code). For influenza virus vaccine claims with dates of service October 1, 2003 and later, use diagnosis code V04.81.
• Influenza virus vaccines require:
• the UPIN SLF000 on claims submitted before May 23, 2007, or
• the provider’s own NPI to be reported in the NPI field for the attending physician on claims submitted on or after May 23, 2007.
Providers conducting mass immunizations are required to complete the following fields on the preprinted Form CMS-1450:
• Type of Bill;
• Total Charges;
• Provider Representative; and
NOTE: Medicare Secondary Payer (MSP) utilization editing is bypassed in CWF for all mass immunization roster bills. However, if the provider knows that a particular group health plan covers the pneumococcal vaccine 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 the pneumococcal and influenza virus vaccines.
Contractors use the beneficiary roster list to generate Form CMS-1450s to process the pneumococcal vaccine claims by mass immunizers indicating condition code M1 to avoid MSP editing. Standard System Maintainers must develop the necessary software to generate Form CMS-1450 records that will process through their system.
Providers that do not mass immunize must continue to bill for the pneumococcal and influenza virus vaccines using the normal billing method, e.g., submission of a Form CMS-1450 or electronic billing for each beneficiary.