Medicare updates influenza vaccine payment allowances

Fall is typically the season for administering influenza vaccine. Accordingly, the Centers for Medicare & Medicaid Services (CMS) recently published its annual update of influenza vaccine payment allowances.

The allowances printed in the update are for dates of services beginning Aug. 1, 2013, and ending July 31, 2014. Medicare administrative contractors have until Oct. 25, 2013, to implement the new payment allowances in their claims processing systems. The payment allowances apply when Medicare payment is based on 95 percent of the average wholesale price, except when furnished in a hospital outpatient department, a Rural Health Clinic, or a Federally Qualified Health Center for which payment is based on reasonable cost.

The update covers a variety of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes used to report influenza vaccine. These include some CPT codes that are new for 2014 and at least one, 90687 (Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use), for which Food and Drug Administration approval is still pending. You can find a list of the new CPT vaccine codes on the American Medical Association’s web site. As the information becomes available, CMS will post payment limits for influenza vaccines that are approved after the update’s release date, including CPT codes 90687 and 90688 (Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use), on the CMS Seasonal Influenza Vaccines Pricing webpage.

When billing for an influenza vaccine administered to a Medicare patient, don’t forget to also report the HCPCS administration code, G0008 (Administration of influenza virus vaccine).

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians