'Tis the season...influenza season, that is

The Centers for Medicare & Medicaid Services (CMS) released its annual update to influenza vaccine payments in early October, effective for dates of service on or after Aug. 1, 2012. Here’s an overview of what your Medicare contractor should be paying you.

CMS has payment allowances for several CPT and HCPCS codes for seasonal influenza virus vaccines. These allowances are typically based on 95 percent of the average wholesale price. However, when physicians furnish the vaccine in a hospital outpatient department, rural health clinic, or federally qualified health center, payment is based on reasonable cost and other allowances may apply.

The following table shows the payment allowances (based on 95 percent of the average wholesale price) for the most common codes:

Note that CMS has permitted payment allowances for some influenza vaccines to be set by the local claims processing contractor. Specifically, local contractors set the payment amounts for Q2034, Influenza virus vaccine, split virus, for intramuscular use (Agriflu), and Q2039, Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified).

Medicare payment for some other influenza vaccine codes is available only after the local claims processing contractor determines that the vaccine in question is medically reasonable and necessary for the beneficiary. These include:

•    90654 – Influenza virus vaccine, split virus, preservative-free, for intradermal use (Fluzone ID); Part B allowance of $18.981,
•    90660 – Influenza virus vaccine, live, for intranasal use (FluMist); Part B allowance of $23.456,
•    90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Fluzone High-Dose); Part B allowance of $30.923.

The additional scrutiny that Medicare is giving these codes is probably due in part to their costs compared with the traditional injectable influenza vaccine. Beyond that, code 90654 is a new code reflecting a new route of administration (i.e., intradermal), and the “enhanced immunogenicity” represented by code 90662 is probably not universally needed, leading Medicare to make sure that those who receive it do so appropriately. Finally, an article published by the Medicare contractor in Florida suggests that 90660 is only indicated for healthy individuals between 2 to 49 years of age, again leading Medicare to ensure that those who receive it do so appropriately.

In closing, it is worth pointing out that the allowances above are effective with dates of service on or after Aug. 1, 2012; however, Medicare contractors have until Dec. 28, 2012, to implement these allowances, so it is possible that some of your influenza vaccine claims may not be paid at the correct rate in the interim. Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors will adjust claims brought to their attention, so if you submitted a claim that is not paid at the correct allowance, you need to bring that claim to the contractor’s attention for adjustment.

For more information, check out the MLN Matters article (MM8047) "Influenza Vaccine Payment Allowances: Annual Update for 2012-2013 Season.”

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