Answer Flu and Pneumonia Vaccine Billing Questions

The “2011-2012 Immunizers’ Question & Answer Guide to Medicare Part B & Medicaid Coverage of Seasonal Influenza and Pneumococcal Vaccinations“ is now available in the Downloads section of the Immunizations page on the Centers for Medicare & Medicaid Services (CMS) website. Also available for download is a mini-poster in English and Spanish that reminds everyone that flu vaccination is covered for Medicare beneficiaries and children eligible for Medicaid and Children’s Health Insurance Program (CHIP).

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October 28th, 2011

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2011-2012 Influenza Vaccine Pricing Now Available

The 2011-2012 seasonal influenza vaccine payment limits are now available on the Centers for Medicare & Medicaid Services (CMS) website.

The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95 percent of the Average Wholesale Price (AWP), except where the vaccine is furnished in a hospital outpatient department. Payment for the vaccine furnished in the hospital outpatient department is based on reasonable cost.

Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations.

Payment allowances effective for dates of service between Sept. 1, 2011 and Aug. 31, 2012 are:

• 90654: $18.383
• 90655: $15.705
• 90656: $12.375
• 90657: $6.653
• 90660: $22.316
• 90662: $30.923
• Q2035 (Afluria): $11.543
• Q2036 (Flulaval): $8.784
• Q2037 (Fluvirin): $13.652
• Q2038 (Fluzone): $13.306
• Q2039 (N.O.S.): locally priced

September 29th, 2011

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2010-11 Seasonal Flu Vaccine Rates

You can find 2010-2011 seasonal influenza vaccine pricing posted on the Centers for Medicare & Medicaid Services (CMS) website. These payment allowances also were published as a part of the October 2010 quarterly Average Sales Price (ASP) Drug Pricing files.

The payment allowance effective for service dates between Sept. 1 and Dec. 31:

The payment allowance effective for service dates between Sept. 1 and Aug. 31, 2011:

Annual Part B deductible and coinsurance amounts do not apply for the flu virus and pneumococcal vaccines.

The Medicare Part B payment allowance limits for seasonal flu and pneumococcal vaccines are 95 percent of the average wholesale price (AWP) as reflected in the published compendia, except where the vaccine is furnished in a hospital outpatient department, at which time the payment allowance is based on reasonable cost.

October 15th, 2010

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October Updates to OPPS and ASC PS Announced

Quarterly updates to the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System (ASC PS) for separately paid drugs and biologicals, covered surgical procedures, and ancillary services have been released to Medicare contractors. The updates include one newly created pass-through device HCPCS Level II code, five newly created drug HCPCS Level II codes, and six newly created HCPCS Level II codes for imaging services.

October 2010 OPPS Pricer and ASC DRUG file

The following five new HCPCS Level II codes have been created for drugs that are payable as covered ancillary services under the OPPS and ASC PS for service dates on or after Oct. 1.

We recently reported on the national coverage analysis (NCA) for Provenge. Until a national coverage determination (NCD) is made by the Centers for Medicare & Medicaid Services (CMS), local contractors will issue local coverage determinations (LCDs) for Provenge based on the medical necessity of the service(s) being provided.

Note: The long descriptor of Provenge stating “all other preparatory procedures” refers to the transportation process of collecting immune cells from a patient during a non-therapeutic leukapheresis procedure, subsequently sending the immune cells to the manufacturing facility, and then transporting the immune cells back to the site of service to be administered to the patient.

Payment Rate Updates

CMS has identified incorrect payment rates for one CPT® code in the April 2010 OPPS Pricer and ASC Drug file and two HPCPS Level II codes in the July 2010 OPPS Pricer and ASC Drug file.

The correct payment rate for CPT® code 90476 Adenovirus vaccine, type 4, live, for oral use is $72.17 and the corrected minimum unadjusted copayment is $14.43, effective for services furnished April 1 - June 30.

Effective for services furnished July 1 - Sept. 30, the correct payment rates for HCPCS Level II codes J9264 Injection, paclitaxel protein-bound particles, 1 mg and C9268 Capsaicin, patch, 10 cm² in the revised July 2010 OPPS Pricer and ASC Drug file are $9.22 and $25.55, respectively. The corrected minimum unadjusted copayments are $1.84 and $5.01, respectively.

Suppliers who think they may have received incorrect payment for 90476 claims processed between April 1 and June 30 or J9264 and C9268 claims processed between July 1 and Sept. 30 may request an adjustment.

Payment Indicator Updates

The payment indicators for two CPT® codes also have been corrected since first being issued. These changes may affect reimbursement rates. Staff should check claims for the following services furnished between the dates indicated to determine if claims adjustments are warranted.

CPT® code 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use was erroneously assigned status indicator K Paid under OPPS; separate APC payment in the July 2010 OPPS update and ASC payment indicator K2 Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate in the July 2010 ASC update.

Effective April 1, the OPPS status indicator for 90670 is changed from K to L Not paid under OPPS. Paid at reasonable cost; not subject to deductible or coinsurance and ASC payment indicator for 90670 is changed from K2 to L1 Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment made. Beginning April 1, 90670 will be paid at reasonable cost and does not appear in the revised April 2010 and revised July 2010 ASC Drug files.

Also changed is the OPPS status indicator for CPT® code 90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use from E to L, and the ASC PI for 90662 from Y5 to L1, effective Dec. 23, 2009, when 90662 received Food and Drug Administration (FDA) approval.

New Pass-Through Device Code

The Outpatient Prospective Payment System (OPPS) adds a new pass-through device code for separate payment, effective Oct. 1.

HCPCS Level II code C1749 Endoscope, retrograde imaging/illumination colonoscope device (implantable) is assigned is assigned OPPS status indicator H Separate cost-based pass-through payment; not subject to coninsurance and ASC payment indicator J7 OPPS pass-through device paid separately when provided integral to a surgical procedure on ASC list; payment contractor-priced.

MRA Coding/Payment Changes

Effective for claims with dates of service on or after June 3, hospitals and ASCs have six new HCPCS Level II codes for billing certain magnetic resonance angiography (MRA) services for which there is no national coverage determination (NCD). Coverage for the following new codes is up to the discretion of your Medicare contractor and its local coverage determinations (LCD).

C8931            Magnetic resonance angiography with contrast, spinal canal

C8932            Magnetic resonance angiography without contrast, spinal canal and contents

C8933            Magnetic resonance angiography without contrast followed by with contrast, spinal canal and contents

C8934            Magnetic resonance angiography with contrast, upper extremity

C8935            Magnetic resonance angiography without contrast, upper extremity

C8936            Magnetic resonance angiography without contrast followed by with contrast, upper extremity

These codes are assigned ASC payment indicator Z2 Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS relative payment weight in the MPFS update, effective June 1 – Nov. 30, as authorized by the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.

Note that, for Medicare claims, HCPCS Level II codes C8931, C8932, and C8933 replace CPT® code 72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s), and HCPCS Level II codes C8934, C8935, and C8936 replace CPT® code 73225 Magnetic resonance angiography, upper extremity, with or without contrast material(s).

CMS has changed the assignment of codes 72159 and 73255 from status indicator E to B to indicate that these codes are not recognized by OPPS when submitted on an outpatient hospital Part B bill type 12x or 13x. Under the OPPS, the six new HCPCS Level II codes are assigned status indicator Q3 to indicate that these services will be paid with one composite APC payment each time a hospital bills for second and subsequent imaging procedures in the same imaging family on a single service date.

Those are the major changes. For complete details, see CMS Transmittal  2050, Change Request (CR) 7117, issued Sept. 17, and Transmittal 2045, CR 7147, issued Sept. 10.

Update: Transmittal 2050, dated September 17, 2010 is rescinded and replaced by Transmittal 2061, dated October 1, 2010. A reference to a special payment indicator (Policy Section 6.B) that incorrectly stated a ‘Y’ has been corrected in the Recurring Update Notification to specify a ‘2’ instead. All other information remains the same.

October 1st, 2010

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J4 MAC Locally Prices Fluzone

Although Fluzone® high-dose influenza virus vaccine, CPT® code 90662 Influenza virus vaccine split virus, preservative free, enhanced immunogenicity via increased antigen content for intramuscular use, was included in the Average Sales Price (ASP) National Drug Code (NDC)-HCPCS Crosswalk, a national payment will not be published by the Centers for Medicare & Medicaid Services (CMS) until later this year. Until the national payment is published, Medicare contractors have been instructed to price the code locally.

TrailBlazer Health announced Sept. 9 that, effective for dates of service on or after July 1, 2010, the payment allowance for CPT® code 90662 is $29.21. TrailBlazer is the Medicare administrative contractor (MAC) for jurisdiction 4, which represents Colorado, New Mexico, Oklahoma, and Texas.

As applicable to influenza vaccines, the payment allowance is based on 95 percent of the Average Wholesale Price (AWP).

The ASP NDC-HCPCS Crosswalk is available on the CMS 2010 ASP Drug Pricing Files web page. Click July 2010 ASP NDC-HCPCS Crosswalk under the Downloads section.

September 10th, 2010

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