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: