Medicare Part B and Part D Vaccine Coverage
Medicare Part B provides preventive coverage only for certain vaccines. These include:
- Influenza: once per flu season (codes 90630, 90653, 90656, 90662, 90673-74, 90682, 90685-88, 90756, Q2035, Q2037, Q2039)
- Pneumococcal: (codes 90670, 90732, once per lifetime with high-risk booster after 5 years)
- Hepatitis B: for persons at intermediate- to high-risk (codes 90739- 90740, 90743-90744, 90746-90747)
Administration services for these preventive vaccines are reported to Medicare using HCPCS codes as follows:
- G0008 administration of influenza virus vaccine
- G0009 administration of pneumococcal vaccine
- G0010 administration of Hepatitis B vaccine
The diagnosis code to report with these preventive vaccines is:
- Z23 Encounter for immunization
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
Whether participating or non-participating in Medicare, physicians must accept assignment of the Medicare vaccine payment rate and may not collect payment from the beneficiary for the vaccine.
Non-participating physicians may choose not to accept assignment on the administration fee. When a non-participating physician or supplier provides the services, the beneficiary is responsible for paying the difference between what the physician or supplier charges and the amount Medicare allows for the administration fee. The limiting charge provision does not apply to the influenza benefit.
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.)
Payment for Part D-covered vaccines and their administration are made solely by the participating prescription drug plan. This includes all preventive vaccines not covered under Medicare Part B.
When providing a Part D covered vaccine to a Medicare patient, the physician should charge the patient for the vaccine and its administration. To facilitate the patient's reimbursement by his or her Part D plan, the physician's office should complete a CMS-1500 claim form for the vaccine and administration service and give it to the patient to file as an unassigned, out-of-network claim.
Some patients may also request a prescription for preventive vaccines and their administration to meet their Part D plan requirements to have this prescription filled by contracted providers (pharmacy and injection clinic).