Payment for Influenza Vaccine and Its Administration

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:

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:

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.

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: