Note: This article was revised on March 7, 2008, to delete a reference to “institutional providers” in the first bullet point regarding the use of HCPCS code G0009. The sentence referencing that code has been changed to begin with “providers” rather than “institutional providers.” All other information remains the same.

Provider Types Affected

Physicians, hospitals, and other providers who bill Medicare contractors (fiscal intermediaries (FI), carriers, or A/B MAC) for providing influenza and pneumococcal vaccines to Medicare beneficiaries

What You Need to Know

CR 5910, from which this article is taken, clarifies CR 5744 (Payment Allowances for the Influenza Virus Vaccine and the Pneumococcal Vaccine When Payment is Based on 95 Percent of the Average Wholesale Price (AWP)), released October 26, 2007. It provides Medicare contractors additional instructions regarding the pediatric pneumococcal vaccine CPT code 90669, and the updated payment allowance for the nasal influenza virus vaccine CPT code 90660.

The Medicare Part B payment allowance for CPT 90660 is $22.031, effective September 19, 2007. Make sure that your billing staffs are aware of these CPT code updates.

Background

Change Request 5744 (Payment Allowances for the Influenza Virus Vaccine and the Pneumococcal Vaccine When Payment is Based on 95 Percent of the Average Wholesale Price (AWP)), released October 26, 2007; provided the payment allowances for Pneumococcal Vaccine Current Procedural Terminology (CPT) codes 90732 and 90669, and Influenza Virus Vaccines CPT codes 90655, 90656, 90657, 90658, and 90660).

CR 5910, from which this article is taken, augments CR 5744 by providing additional instructions regarding pediatric pneumococcal vaccine CPT code 90669, and the updated payment allowance for the nasal influenza virus vaccine CPT code 90660. These changes are:

• CPT Code 90669 – Effective January 1, 2008, FIs, carriers, and A/B MACs will accept claims containing 90669 for pneumococcal vaccine. In order to facilitate appropriate payment for CPT code 90669 (Pneumococcal conjugate vaccine, polyvalent, for children under five years, for intramuscular use), carriers and A/B MACs will use a payment indicator of “1” and the deductible indicator of “1.” Providers should bill HCPCS code G0009 when billing for services on or after January 1, 2008, for the administration of CPT code 90669.
• CPT Code 90660 - On September 19, 2007, the Food and Drug Administration (FDA) approved FluMist for the 2007-2008 influenza season. Thus, your FI, carrier, or A/B MAC may cover CPT 90660 (FluMist, a nasal influenza vaccine) if it determines that its use is medically reasonable and necessary for the beneficiary. The Medicare Part B payment allowance for CPT 90660 is $22.031, effective September 19, 2007, except where the vaccine is furnished in the hospital outpatient department. This supersedes the allowance figure provided in CR 5744.

Note: All other instructions in CR 5744 remain in effect.

Please note that, except when the vaccine is furnished in the hospital outpatient department, the Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the average wholesale price (AWP), as reflected in the published compendia payment for the vaccine is based on reasonable cost.

Also note that annual Part B deductible and coinsurance amounts do not apply; and that all physicians, non-physician practitioners, and suppliers who administer the influenza virus and pneumococcal vaccinations must take assignment on the claim for the vaccine.

Finally, your Medicare contractor will not search their files to either retract payment for claims already paid or to retroactively pay claims, but will adjust claims that you bring to their attention.

Additional Information

You can find more information about the additional information regarding CPT codes 90669 and 90660 by going to CR 5910, located at http://www.cms.hhs.gov/Transmittals/downloads/R1461CP.pdf on the CMS Web site. You might also want to review the MLN Matters article related to CR 5744. You can find that article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5744.pdf on the CMS Web site.

If you have any questions, please contact your FI, carrier, or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2007 American Medical Association.