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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:


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:
  • Shop early
  • Buy direct and collectively
  • Give more efficiently
  • Bill completely
  • Use Medicare roster billing
Immunization Resources

Part I: AAFP Immunization Schedules

Recommended Adult Immunization Schedule 2007-2008 (*PDF file)

Recommended Childhood Immunization Schedule 2008

Recommended Adolescent Immunization Schedule 2008 (*PDF file)

Recommended Child and Adolescent Immunization Catch-up Schedule 2008 (*PDF file)

Part II: AAFP Immunization Information

Expanded Recommendation for Influenza Immunization for All Children From Age 6 Months Through 18 Years

Interim Recommendations for the Use of Hib-Containing Vaccines

AAFP Policy Statement Regarding Consideration of the Mandated Use of HPV for School Attendance

Immunization Stickers

General Recommendations (*PDF file)

Payment, Adult Immunization (AAFP Policy)

Smallpox Immunization

2002 Smallpox Statement

AAFP Urges ABC to Cancel Show With Misleading Info About Vaccines, Autism

CDC: ABC to Air Legal Drama About Vaccines and Autism

Part III: Influenza Vaccine Information

Immunization Against Influenza 2007-2008

Payment for Influenza Vaccine and Its Administration

CDC Influenza Home Page

CDC Influenza Vaccine Bulletins

Reporting Distributor Influenza Vaccine Problems

Part IV: Information from the CDC

Haemophilus influenza type b (Hib) Vaccine Voluntary Recall (**Word file)

Merck & Co, Inc. Hib Vaccine Shortage: Updated November 16, 2007 (*PDF file)

Merck & Co, Inc. Current Vaccine Supply Status: Updated August 28, 2007 (*PDF file)

CDC Current Vaccine Delays and Shortages

CDC Pre-Teen Vaccine Campaign

CDC Publications

CDC: HPV Vaccine Safety Efficacy Questions and Answers

CDC Flu Gallery

Notice to Readers: Update on Supply of Vaccines Containing Varicella-Zoster Virus

Centers for Disease Control and Prevention (CDC)

CDC-Information: New Immunization Hotline

Vaccine Information Statements

Part V: Information from Other Organizations

Vaccine Adverse Event Reporting System (VAERS)

Shots 2007 for Palm OS and Pocket PC

National Network for Immunization Information (NNii)

Strengthening Adult Immunization: A Call to Action

NFID S.T.O.P Meningitis Tool Kit

(*PDF file. About PDFs)
(**Word file. About Downloading)
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