Payment for Influenza Vaccine and Its Administration

Medicare

As of November 16, 2007
Medicare covers annual influenza immunizations for Medicare beneficiaries. Medicare covers both the cost of the vaccine and its administration. Medicare coinsurance and deductible do not apply (i.e., there is no beneficiary cost-sharing associated with the benefit).
There are four influenza vaccine codes. Those codes and their current Medicare allowances are:

Code	Descriptor	Medicare Allowance
90655	Influenza virus vaccine, split virus, preservative-free, when administered to children 6-35 months of age, for intramuscular use	$16.109
90656	Influenza virus vaccine, split virus, preservative-free, when adminstered to individuals in individuals 3 years and older, for intramuscular use	$17.366
90657	Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use	$6.609
90658	Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use	$13.218
90660	Influenza virus vaccine, live, for intranasal use	$21.176

Administration of the vaccine is separately coded under Medicare using code G0008. This is paid at a rate of $19.33 (unadjusted geographically). In addition, if a significant, separately identifiable evaluation and management (E/M) service (e.g., office visit) is provided, Medicare will cover and pay for it (assuming it is medically necessary and otherwise meets Medicare coverage criteria).

For more information on Medicare coverage and payment for influenza vaccine and its administration, consult the following resources:

"How to Bill Medicare for Influenza and Pneumococcal Vaccinations" (2-page PDF file. More information about PDFs.)
"Pneumococcal Pneumonia, Influenza Virus and Hepatitis B Vaccines" from Chapter 18 of the Medicare Claims Processing Manual (145-page PDF file. More information about PDFs.)
"Adult Immunization Resources for Providers"

Private Payers

Less is known about private payers' coverage and payment for influenza vaccine and its administration. Physicians would use the same CPT codes for the vaccine itself. However, administration of the vaccine would typically be reported with one of the CPT codes for vaccine administration: 90465-90474. Payment rates for both the vaccine and its administration are unknown and would vary depending upon the insurer and particular insurance product.

With respect to E/M services provided on the same date, we do know that Aetna and UnitedHealthcare both pay for all three codes (i.e., the vaccine, its administration and the associated E/M service). However, other payers bundle the administration code with an E/M. Obviously, there is a greater financial benefit to payers covering the influenza vaccine compared with other vaccines, because the benefits are more proximate to the immunization.

Practice Costs

Physicians cannot typically control what suppliers charge for the influenza vaccine or what payers, public and private, pay for the vaccine and its administration. However, they can exercise some control over their associated costs. Here are some following ways physician practices can control their costs of providing influenza immunizations: