Adult Immunization Resources for Providers

This page provides information, resources, and tools to help support clinicians, including community vaccinators, in delivering and billing Medicare for influenza, pneumococcal, and hepatitis B vaccinations.

Pneumonia and influenza are the fifth leading cause of death in older adults in the U.S. While vaccines are available to prevent and reduce complications from these diseases, their use is suboptimal. African Americans and Hispanics have significantly lower influenza and pneumococcal immunization rates compared to the rest of the population. While influenza vaccination coverage rates for whites age 65 and older is 68%, it is only 48% for African Americans, and 54% for Hispanics. The gap for pneumococcal vaccination coverage is even wider, with 60% of whites reporting they have ever received this vaccine, compared with 38% for African Americans, and 36% for Hispanics. (Source: CDC's Behavioral Risk Factor Surveillance System, 1999 and 2001).

Nursing home residents are especially vulnerable to influenza and pneumonia, and their complications. In October of 2005, CMS began requiring as a condition of participation in the Medicare and Medicaid programs that nursing homes ensure that their residents receive influenza and pneumoccoal vaccinations. As a Medicare condition of participation, the rule requires that long-term care facilities ensure that each resident is:

• offered influenza immunization annually;
• immunized against influenza unless medically contraindicated or when the resident or the resident's legal representative refuses immunization;
• offered pneumococcal immunization once if there is no history of immunization; and
• immunized against pneumococcal disease unless medically contraindicated or when the resident or the resident's legal representative refuses immunization.

In the case of a vaccine shortage as declared by CDC, state survey agencies would have the discretion not to cite facilities for being out-of­compliance with this requirement.

Coverage

Influenza immunization: Medicare pays for one influenza immunization each influenza season for all beneficiaries. No coinsurance or co-payment applies to this benefit, and an individual does not have to meet his or her deductible to receive the benefit. Medicare pays separate rates for the administration and cost of the influenza vaccine.

Effective September 1, 2008, the influenza vaccine reimbursement rates are as follows:

90655 Flu vaccine, for children 6 – 35 months, preservative free, 0.50 ML, $16.88.

90656 Flu vaccine, 3 years old and up, preservative free, 0.50 ML $18.20

90657 Flu vaccine, for children 6 - 35 months, 0.25 ML $6.61.

90658 Flu vaccine age 3 years old and up, 0.5 ML $13.22.

90660 Flu vaccine, nasal 0.5 ML $22.32.

Administration rates appear in the 2008-2009 Immunizers' Question & Answer Guide to Medicare Coverage of Influenza and Pneumococcal Vaccinations.

Pneumococcal vaccination: Medicare pays for one pneumococcal vaccination for all beneficiaries. One vaccine at age 65 generally provides coverage for a lifetime, but for some high risk persons, a booster vaccine is needed. Medicare will also pay for the booster vaccination for high risk persons if 5 years have passed since their last vaccination. No coinsurance or co-payment applies to this benefit, and an individual does not have to meet his or her deductible to receive the benefit. Medicare pays separate rates for the administration and cost of the pneumococcal vaccine.  Effective September 1, 2008, the pneumoccal polysaccharide vaccine reimbursement rate is $32.70.  The rate for the pneumococcal conjugate vaccine is $78.80.

Administration rates appear in the 2008-2009 Immunizers' Question & Answer Guide to Medicare Coverage of Influenza and Pneumococcal Vaccinations.

Hepatitis B vaccination: Medicare pays for hepatitis B vaccinations for individuals considered to be at high or intermediate risk. High risk individuals include persons with end stage renal disease, persons with hemophilia who received Factor VIII or IX concentrates, clients of institutions for the mentally handicapped, homosexual men, persons who live with a person who is a hepatitis B virus carrier, and illicit drug users. Individuals at intermediate risk include staff in institutions for the mentally handicapped, and workers in health care professions who have frequent contact with blood or blood-derived body fluids during their work. The Medicare Part B deductible and coinsurance or co-payment applies to this benefit. Medicare pays separate rates for the administration and cost of the hepatitis B vaccine. A doctor of medicine or osteopathy must order hepatitis B vaccination, but does not have to be present during the delivery of the service unless State law requires his or her presence.

Billing

Two procedure codes need to be on a claim for Medicare reimbursement for each type of vaccination. One code is for cost of the vaccine itself, and the other code is for the cost of the administration of the vaccine. Medicare providers/suppliers may bill for vaccinations the same way they bill for other services using either 1500 or 1450 paper claim forms or electronically.

Individuals and entities interested only in delivering vaccinations must enroll as a Medicare provider. If they are interested in becoming "mass immunizers," which are allowed to provide flu and/or pneumococcal vaccinations to a large number of beneficiaries, they must also enroll and follow the special instructions for mass immunizers. Mass immunizers, also known as community vaccinators, often provide influenza and pneumococcal vaccinations in non-traditional settings, such as churches and grocery stores. Existing providers and suppliers that wish to provide mass immunization services must also obtain a provider specialty number to become mass immunizers. Instructions for enrolling as a traditional Medicare provider or supplier, or as a mass immunizer are contained in the links below.

Mass immunizers have two options for how they bill:

1) Roster billing allows mass immunizers to complete one 1500 or 1450 paper form with the type of vaccination (influenza or pneumococcal) and attach a roster listing the beneficiaries who received that type of vaccination, rather than submitting separate 1500 or 1450 paper claim forms for each individual.

2) Centralized billing allows mass immunizers to submit influenza and pneumococcal vaccination claims to a single carrier for processing regardless of the geographic locality in which the vaccination was delivered. Centralized billing is available for mass immunizers that serve beneficiaries in 3 or more states.

The links below include more details on these billing options, and step-by-step instructions for how to bill Medicare and what forms to use.

*Mass immunizers may not deliver hepatitis B vaccinations. Roster billing and centralized billing are not allowed for hepatitis B vaccinations.

Best practices for improving the delivery of vaccinations

A variety of resources are available that provide information on improving the delivery of vaccinations. Links to these resources are provided below.

One method that the evidence suggests is effective is standing orders programs, which allow nurses and pharmacists, where permitted by state law, to administer vaccinations according to an institution or physician-approved protocol without the need for a physician's examination or direct order. Standing orders are permissible and are encouraged when providing mass immunizations because they make it easier and faster to provide influenza and pneumococcal vaccinations.

*In October 2002, CMS removed its requirement from the Conditions of Participation that an individual physician must write an order for each influenza and pneumococcal vaccination given in hospital and long term care settings, and by home health agencies. The links below include information on implementing standing orders programs.

Important resources for providers

Preventive Services Educational Products For Health Care Professionals ~ CMS has developed a variety of educational products for health care professionals to help increase awareness of preventive services covered by Medicare and provide coverage and billing information needed to effectively bill Medicare for preventive services provided to Medicare patients.

The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. The Medicare Learning Network contains information and resources, including "MLN Matters" articles containing guidelines for billing and payment for vaccination services, the 2005 payment rates, and brochures and educational tools that can be downloaded and ordered.

Downloads
2008-2009 Immunizers' Question & Answer Guide to Medicare Coverage of Influenza and Pneumococcal Vaccinations (PDF, 291K)
Related Links Inside CMS
Influenza and Pneumococcal Vaccines Pricing (Sept. 2008) Medicare Benefit Policy Manual, Chapter 15, Section 50.4.4.2, Immunizations Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services MLN Matters: 08-09 Influenza Resources for Healthcare Professionals Medicare Learning Network Quick Reference Information--Medicare Preventive Services Quick Reference Information: Medicare Immunization Billing Chart The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals (page 95) 2008 Reminder for Roster Billing/Centralized Billing for Influenza & Pneumoccal Vaccinations Payment Allowance Update for Influenza Virus Vaccine CPT 90660, Further Instruction Regarding Pneumoccal Vaccine CPT 90669
Related Links Outside CMS
CDC Vaccines Website CDC Influenza Website Facilitating Influenza and Pneumococcal Vaccinations through Standing Orders Standing Orders Protocol to Increase Adult Immunization Rates Vaccine Management: Recommendations for Storage and Handling Selected Biologicals

Page Last Modified: 11/19/2008 1:22:25 PM
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