CMS had fixed a payment of $23.467 for the 2015-2016 flu season.
The CPT® added a new influenza vaccine code 90630 (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use) on January 1, 2015. This code was out of bounds for payment purposes until August 1, 2015 because the Food and Drug Administration (FDA) had not yet granted final approval for the vaccine and has since granted approval. CMS also indicated in Change Request ("CR") 9357 released December 22, 2015 that some claims with this code may have been denied.
Good news: The CR provides instruction for Medicare systems to be updated to include CPT® 90630 are payable by Medicare. If you see a denial indicating the code was denied as invalid, Medicare requests refiling the claim. Remember that the annual Part B deductible and coinsurance for this code do not apply. Read more about this at:
Watch the patient's age: This single dose intradermal vaccine is typically given to patients in the 18-64 year age bracket.
The FDA approval: Even though the code 90630 was introduced in the beginning of 2015, it carried a lightning bolt sign in CPT® 2015, indicating that the code was still awaiting FDA approval. "The FDA granted approval of the vaccine on December 11, 2014, which was too late to be captured in the 2015 edition of CPT®," notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. "The lightning bolt symbol will not appear next to 90630 in the 2016 edition," adds Moore.
Reason to cheer: CMS, in its Medicare Learning Network (MLN) Matters Article No. MM9357 Revised Dec. 22, 2015, wherein it has provided instructions for Medicare systems to be updated to include influenza virus vaccine code 90630 for claims with dates of service on or after August 1, 2015 (and processed on or after April 4, 2016). The article informs you that your Medicare administrative contractor (MAC) will add influenza virus vaccine CPT® code 90630 to existing influenza virus vaccine edits and accept it for claims with dates of service on or after August 1, 2015.
Understand the Amount of Reimbursement You Can Expect For 90630
According to CMS, "the Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95% of the Average Wholesale Price (AWP)" except where the vaccine is furnished in a hospital outpatient department. When the vaccine is furnished in the hospital outpatient department, payment for the vaccine is based on reasonable cost.
The Center for Disease Control and Prevention (CDC) has changed some of its recommendations for prevention and control of influenza. In these recommendations, it states that the "vaccine efforts should begin as soon as the seasonal influenza vaccine is available and continue through the influenza season." To conform to these CDC recommendations, CMS has now changed the payment limit effective date relative to flu season from September 1 to August 1. Accordingly, the payment allowance that CMS has fixed for code 90630 for the 2015-2016 flu season (August 1, 2015, through July 31, 2016) is $23.467.
Remember: Medicare continues to cover many seasonal influenza vaccines without application of coinsurance or the annual Part B deductible. This is true when you are reporting 90630, too.
The MLN Matters article also informs that MACs will hold institutional claims containing influenza virus vaccine CPT® code 90630 (with dates of service on or after August 1, 2015) that they receive before April 4, 2016.
Once the system changes described in CR9357 are implemented, these institutional claims will be processed and paid. "Unfortunately, neither MM9357 nor the corresponding change request to the MACs references professional claim holding for 90630 received before April 4, 2016," Moore observes.
Finally, don't forget to also report an appropriate code for administration of the flu vaccine, since code 90630 only covers the vaccine itself. For Medicare patients, you should use code G0008 (Administration of influenza virus vaccine). For non-Medicare patients, consider an appropriate CPT® code from the range 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) – 90472 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]).
For more information, check the MLN article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9357.pdf and https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html.