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Medicare Part B Vaccine Coverage
- Influenza - once per flu season (Codes 90655-90658, 90660, 90662)
- Pneumococcal - once per lifetime (Codes 90669 and 90732)
- Hepatitis B - for persons at intermediate to high risk (Codes 90740, 90743, 90744, 90746, 90747)
- G0008 Administration of influenza virus vaccine
- G0009 Administration of pneumococcal vaccine
- G0010 Administration of Hepatitis B vaccine
- V04.81 when influenza vaccine is administered but pneumococcal is not
- V06.6 when both the influenza and pneumococcal vaccines are administered
- V03.82 when administering pneumococcal vaccine but not the influenza vaccine
- V05.3 when administering the hepatitis B vaccine
Other immunizations are covered under Medicare Part B only if they are directly related to the treatment of an injury or direct exposure, such as antirabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin or immune globulin.
Coverage of other vaccines provided as a preventive service may be covered under a patient's Part D coverage.
Billing Considerations for Part B Vaccines
The influenza and pneumococcal vaccines and the administration of these vaccines are not subject to the Medicare Part B deductible or co-insurance. Medicare pays at 100% of the allowable amounts. However, the Hepatitis B vaccine and administration are subject to the deductible and co-insurance. Medicare pays at 80% after the patient has met their Part B deductible.
Medicare will pay two administration fees if a beneficiary receives both the influenza virus and the pneumococcal vaccine on the same day.
Claims for the hepatitis B vaccine must include the name and NPI of the ordering physician, as Medicare requires that the hepatitis B vaccine be administered under a physician’s order with supervision. This is not necessary for the influenza and pneumococcal vaccines for which Medicare does not require a physician's order or supervision. (Note that state law may require an order and/or supervision.)
Medicare Allowed Amounts for Preventive Vaccines
The influenza vaccine allowables are posted by CMS each year. The allowables for the pneumococcal and hepatitis B vaccines are included in the average sale price files listed on the CMS site as ASP Drug Pricing Files. These files are updated quarterly by CMS and often show retroactive updates to pricing information. When there is an increase in your costs for a vaccine that is put in place prior to the CMS updates to their pricing files, it may be worthwhile to request an adjustment to previously paid claims.
The Medicare allowable for the vaccine administration codes will be the same as the amount allowed for CPT code 90471, which is the code for immunization administration provided to adults or provided to children without physician counseling (e.g., doses of childhood vaccine series subsequent to the first dose).