News Flash – The revised publication titled End-Stage Renal Disease Composite Payment Rate System (September 2010) (previously titled Outpatient Maintenance Dialysis - End-Stage Renal Disease) provides information about the Medicare End-Stage Renal Disease composite payment rate system, the one-time election and transition period, and separately billable items and services. This publication can be accessed at http://www.cms.gov/MLNProducts/downloads/ESRDpaymtfctsht2010.pdf on the CMS website.
Note: This article was revised on December 9, 2010 , to correct the short descriptor for code Q2039 on page 2. All other information is the same.
Provider Types Affected
This article is for physicians and providers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/or Part A/B Medicare Administrative Contractors (A/B MACs)) for influenza vaccines provided to Medicare beneficiaries.
Provider Action Needed
The article is based on Change Request (CR) 7234 which establishes separate billing codes for each brand-name influenza vaccine product under Common Procedure Terminology (CPT) code 90658 and describes the process for updating the new specific Healthcare Common Procedure Coding System (HCPCS) codes and their payment allowances for Medicare during the 2010-2011 influenza season.
Background
CMS has created specific HCPCS codes and payment allowances to replace CPT code 90658 for Medicare billing purposes for the 2010-2011 influenza season.
Key Points of CR7234
The following describes the process for updating these specific HCPCS codes for Medicare payment effective for dates of service on or after October 1, 2010.
Effective for claims with dates of service on or after January 1, 2011, the following CPT code will no longer be payable for Medicare: CPT Code
Short Description
Long Description
90658
Flu vaccine, 3 yrs & >, im
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Effective for claims with dates of service on or after October 1, 2010, the following HCPCS codes will be payable for Medicare: HCPCS Code
Short Description
Long Description
Q2035
Afluria vacc, 3 yrs & >, im
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036
Flulaval vacc, 3 yrs & >, im
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037
Fluvirin vacc, 3 yrs & >, im
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
Q2038
Fluzone vacc, 3 yrs & >, im
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039
NOS flu vacc, 3 yrs & >, im
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)
Take Note: CPT 90658 describes the regular dose vaccine that is supplied in a multi-dose vial for use in patients over 3 years of age. For dates of service on or after October 1, 2010, HCPCS codes Q2035, Q2036, Q2037, Q2038 and Q2039 (as listed in the table above) will replace the CPT code 90658 for Medicare payment purposes during the 2010 – 2011 influenza season. However, these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011 , when CPT code 90658 will no longer be recognized.
This instruction does not affect any other CPT codes. It is very important to distinguish between the various CPT and HCPCS codes which describe the different formulations of the influenza vaccines (i.e. pediatric dose, regular dose, high dose, preservative free, etc.). As a reference, the quarterly Part B drug pricing files includes a set of National Drug Code (NDC) to HCPCS crosswalks available online at http://www.cms.gov/McrPartBDrugAvgSalesPrice/on the Centers for Medicare & Medicaid Services (CMS) website.
Billing
In general, it is inappropriate for a provider to submit two claims for the same service on the same date. For dates of service between October 1, 2010 and December 31, 2010 , the CPT 90658 and the Q-codes will be valid for billing; however, providers may not bill Medicare for both the CPT 90658 and any of the Q-codes for the same patient for the same date of service. Thus, if a provider vaccinates a beneficiary on any date between October 1, 2010 and December 31, 2010 , the provider may either bill Medicare immediately using CPT 90658, or hold the claim and wait until January 1, 2011 to bill Medicare using the most appropriate Q-code. If a claim has already been submitted and processed using CPT 90658, then there is no need to use the Q-code for that same service.
For dates of service on or after January 1, 2011, providers may only bill Medicare for one of the HCPCS codes that appropriately describes the specific vaccine product administered.
Payment
The Medicare Part B payment limits for influenza vaccines are 95 percent of the Average Wholesale Price (AWP) except where the vaccine is furnished in a setting that follows a cost-based or prospective payment system under Medicare. For example, where the vaccine is furnished in the hospital outpatient department, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC), payment for the vaccine is based on reasonable cost.
For dates of service on or after October 1, 2010 , the Medicare Part B payment allowances in other situations are: HCPCS Code
Allowance
Q2036
$7.439
Q2037
$13.253
Q2038
$12.593
No national payment limits are available for Q2035 and Q2039. The payment limits for these two codes will be determined by the local claims processing contractor.
For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.
Important Notes:
Annual Part B deductible and coinsurance amounts do not apply to these vaccines. All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.
Be aware that Medicare contractors will not search their files to adjust payment on claims paid incorrectly prior to implementing CR7324. However, they will adjust such claims that you bring to their attention.
Additional Information
If you have questions, please contact your Medicare A/B MAC, carrier or FI at their toll-free number, which may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.
For complete details regarding this CR please see the official instruction (CR7234) issued to your Medicare A/B MAC, carrier or FI. That instruction may be viewed by going to http://www.cms.gov/Transmittals/downloads/R815OTN.pdf on the CMS website.
CMS would like providers to be aware that educational products are available through the MLN Catalogue free of charge. The MLN Catalogue is available at http://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf on the CMS website. The specific products that may be of interest to providers who use the information in MM7234 are as follows:
1. The Medicare Preventive Services Quick Reference Information Chart: Medicare Part B Immunization Billing (Influenza, Pneumococcal, and Hepatitis B) is available at http://www.cms.gov/MLNProducts/downloads/qr_immun_bill.pdf on the CMS website.
2. The Adult Immunizations brochure provides a basic overview of Medicare’s influenza, pneumococcal and hepatitis B vaccine benefits and is available at http://www.cms.gov/MLNProducts/downloads/Adult_Immunization.pdf on the CMS website.
News Flash - Each Office Visit is an Opportunity . Medicare patients give many reasons for not getting their annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United States each year, on average. More than 90% of these deaths occur in people 65 years of age and older. Please talk with your Medicare patients about the importance of getting their annual flu vaccination. This Medicare-covered preventive service will protect them for the entire flu season. And remember, vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’t forget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of the influenza vaccine and its administration, as well as related educational resources for health care professionals and their staff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf and http://www.cms.gov/AdultImmunizations on the CMS website.
Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.
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