Billing for Influenza Vaccines

on Tuesday, 21 May 2019. All News Items | Billing

An Ounce of Prevention is Worth a Pound of Cure

There is a new trend going around FaceBook of describing your age by memories and events instead of a number. For example, I am “Walt Disney's Wonderful World of Color on Sunday nights” old. In fact, I am so old that I actually had the measles as a child. Unfortunately, this is becoming a new “event” of present day and a very scary one at that. I had a very light case of the measles as a child, but my little brother was extremely ill, only avoiding hospitalization because our family doctor made frequent house calls to check on him (another phenomenon of the past). The key to preventing a new epidemic of this life-threatening disease is to get the measles vaccine. There are other vaccines that are recommended for children and adults. I am traveling out of the country soon and got two vaccines this week based on the CDC recommendations for travelers. Pediatricians usually keep up with the recommended vaccines for children, but it is harder for adults. Here is an excellent article from NPR about adult vaccines.

Medicare covers vaccines for influenza, pneumococcal pneumonia, and hepatitis B (for higher risk individuals). As always for providers of Medicare services, where there are services provided, there are billing rules. Recently NGS, the Medicare Administrative Contractor (MAC) for Jurisdictions 6 and K, featured influenza vaccines as the topic of their Medicare BLAST. Medicare BLAST is a quick, ten-question game from NGS that challenges the Medicare knowledge of providers and one of the most creative and fun educational tools I’ve encountered.

Here is some information about Influenza Vaccines from the Medicare BLAST and other Medicare resources.

  • Influenza vaccines are payable once per flu season. For Medicare pricing purposes the season runs from August to July of the following year, such as from August 2018-July 2019. Frequency limits are based on the flu season, not the calendar year, so a Medicare patient could receive two flu vaccines in the same calendar year. For example, if a Medicare beneficiary gets a shot in January 2019 for the 2018/2019 flu season, they could get another shot in October 2019 for the 2019/2020 flu season.
  • Medicare patients can receive an influenza vaccine and a pneumococcal pneumonia vaccine during the same visit. The administration codes (G0008 and G0009 respectively) may be billed together on the same claim for the same date of service. A modifier is not needed when billing the two administration codes for the influenza and pneumococcal vaccine.
  • The Part B deductible, coinsurance, or copayment do not apply to the seasonal influenza virus vaccine or its administration. Medicare covers the vaccine as long as the patient is eligible for and enrolled in Traditional Medicare.
  • Medicare does not require that a doctor order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision. A physician is not required to be present during the administration of the influenza vaccine.
  • Vaccines provided to inpatients of a hospital are covered under the vaccine benefit. The hospital bills on type of bill 012x using the discharge date of the hospital stay or the date benefits are exhausted.
  • Hospital providers should bill for the vaccines and their administration on the same bill. Hospitals are paid at reasonable cost for the vaccine and under the OPPS payment rate for the vaccine administration.
  • Simplified (roster) billing procedures are available to mass immunizers, including hospitals. See section 10.3.2 of the Chapter 18 of the Medicare Claims Processing Manual for more information on roster billing.

In addition to Section 10 of the Medicare Claims Processing Manual, Chapter 18 (at the link above), another good resource on Medicare vaccines is the MLN Educational Tool on Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B.

People have differing opinions about vaccines, but I am solidly for them. I went to elementary school with a little girl who wore braces from polio, my brother could have died from the measles, my grandfather was one of the few survivors at his Army base of the flu pandemic of 1918, and years ago I thought I was going to die from the flu. I have taken the flu vaccine every year since. Not all vaccines are 100% effective and there may be some side effects, but overall, they help protect you and those around you from serious illnesses.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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