FI/AB MAC Payment for Pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus Vaccines and Their Administration (Rev. 1586, 10-06-08)

by  Jared Staheli
June 25th, 2015

Payment for Vaccines

Payment for all of these vaccines is on a reasonable cost basis for hospitals, home health agencies (HHAs), skilled nursing facilities (SNFs), critical access hospitals (CAHs), and hospital-based renal dialysis facilities (RDFs). Payment for comprehensive outpatient rehabilitation facilities (CORFs), Indian Health Service hospitals (IHS), IHS CAHs and independent RDFs is based on 95 percent of the average wholesale price (AWP). Section 10.2.4 of this chapter contains information on payment of these vaccines when provided by RDFs or hospices. See §10.2.2.2 for payment to independent and provider- based Rural Health Centers and Federally Qualified Health Clinics.

Payment for these vaccines is as follows:

Facility Type of Bill Payment
Hospitals, other than Indian Health Service (IHS) Hospitals and Critical Access Hospitals (CAHs) 12x, 13x Reasonable cost
IHS Hospitals 12x, 13x, 83x 95% of AWP
IHS CAHs 85x 95% of AWP
CAHs 85x Reasonable cost
Method I and Method II    
Skilled Nursing Facilities 22x, 23x Reasonable cost
Home Health Agencies 34x Reasonable cost
Comprehensive Outpatient Rehabilitation Facilities 75x 95% of the AWP
Independent Renal Dialysis Facilities 72x 95% of the AWP
Hospital-based Renal Dialysis Facilities 72x Reasonable cost

 

Payment for Vaccine Administration

Payment for the administration of influenza virus and pneumococcal vaccines is as follows:

Facility Type of Bill Payment
Hospitals, other than IHS Hospitals and CAHs 12x, 13x

Outpatient Prospective Payment System (OPPS) for hospitals subject to OPPS

Reasonable cost for hospitals not subject to OPPS

IHS Hospitals 12x, 13x, 83x MPFS as indicated in guidelines below.
IHS CAHs 85x MPFS as indicated in guidelines below.
CAHs 85x Reasonable cost
Method I and II    
Skilled Nursing Facilities 22x, 23x MPFS as indicated in the guidelines below
Home Health Agencies 34x OPPS
Comprehensive Outpatient Rehabilitation Facilities 75x MPFS as indicated in the guidelines below
Independent RDFs 72x MPFS as indicated in the guidelines below
Hospital-based RDFs 72x Reasonable cost

Guidelines for pricing pneumococcal and influenza virus vaccine administration under the MPFS.

Make reimbursement based on the rate in the MPFS associated with the CPT code 90782 or 90471 as follows:

HCPCS code Effective prior to March 1, 2003 Effective on and after March 1, 2003
G0008 90782 90471
G0009 90782 90471

See §10.2.2.2 for payment to independent and provider based Rural Health Centers and Federally Qualified Health Clinics.

Payment for the administration of hepatitis B vaccine is as follows:

Facility Type of Bill Payment
Hospitals other than IHS hospitals and CAHs 12x, 13x

Outpatient Prospective Payment System (OPPS) for hospitals subject to OPPS

Reasonable cost for hospitals not subject to OPPS

IHS Hospitals 12x, 13x, 83x MPFS as indicated in the guidelines below
CAHs 85x Reasonable cost
Method I and II    
IHS CAHs 85x MPFS as indicated in guidelines below.
Skilled Nursing Facilities 22x, 23x MPFS as indicated in the chart below
Home Health Agencies 34x OPPS
Comprehensive Outpatient Rehabilitation Facilities 75x MPFS as indicated in the guidelines below
Independent RDFs 72x MPFS as indicated in the chart below
Hospital-based RDFs 72x Reasonable cost

Guidelines for pricing hepatitis B vaccine administration under the MPFS.

Make reimbursement based on the rate in the MPFS associated with the CPT code 90782 or 90471 as follows:

HCPCS code Effective prior to March 1, 2003 Effective on and after March 1, 2003
G0010 90782 90471

See §10.2.2.2 for payment to independent and provider based Rural Health Centers and Federally Qualified Health Clinics.

References:

FI/AB MAC Payment for Pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus Vaccines and Their Administration (Rev. 1586, 10-06-08). (2015, June 25). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/fi-ab-mac-payment-for-pneumococcal-pneumonia-virus-influenza-virus-and-hepatitis-b-virus-vaccines-and-their-administration-rev-1586-10-06-08-26899.html

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