- Medicare Hospice Quick Reference Sheet
- Hospice Certifying Physician Medicare Enrollment Information
- Hospice Notice of Election Termination/Revocation
- Hospice Room and Board Denials
- Professional Services During a Patient Hospice Election
- Tips to Facilitate the Change of Ownership Process
- Service Intensity Add-on Payment
- Counting 60-Day Election Periods
- Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
- Hospice Billing Codes Chart
- Appropriate Use of Occurrence Code 27 and Occurrence Span Code 77
- Avoiding Reason Code U5181: Appropriate Use of Occurrence Code 27/Occurrence Span Code 77
- Hospice Notice of Change of Ownership
- Filing an Electronic Notice of Change of Ownership (TOB 8XE)
- Hospice Change of Ownership
- Filing an Electronic Notice of Cancelation (Type of Bill 8XD)
- Filing an Appeal for Claims Rejected for an Untimely Hospice Notice of Election
- Filing an Electronic Notice of Transfer (Type of Bill 8XC)
- Counting 60-Day Election Periods - Leap Year
- Hospice Site of Service Codes
- Billing Hospice Physician, Nurse Practitioner and Physician Assistant Services (Related To Terminal Diagnosis)
- Correcting Hospice Claims Sequentially to Avoid Reason Code U5181
- Common Working File System Edit F5052 and M5052
- Hospice Visit Reporting
- The Medicare Hospice Benefit: Effects on Other Provider Types
- Counting 90-Day Election Periods - Leap Year
- Reporting Hospice Discharges, Revocations and Transfers
- Filing an Electronic Notice of Termination-Revocation of Election (Type of Bill 8XB)
- Avoiding Reason Code 7C625: Appropriate Use of Remarks on Final Hospice Claims
- Notice of Election: Timely Filing of Hospice Elections
- Hospice Claim Submission Job Aid
- Direct Mailing Notification to Hospice Providers Regarding the Hospice Benefit Component, VBID Model, Participating MAOs
- Counting 90-Day Election Periods
- Hospice Quality Reporting Program
- Filing an Electronic Notice of Election (Type of Bill 8XA)
- Hospice Prescription Drug and Infusion Pump Reporting
- Hospice Caps Job Aid
- Value-Based Insurance Design Model Hospice Benefit Component Overview
- Documentation for Hospice Transfers
- Hospice Billing Instructions for Influenza, Pneumococcal and Hepatitis B Vaccines
- Appropriate Use of Condition Code 85
- How to Correct/Avoid Reason Code U5150
- General Inpatient Check Off List
- Hospice Transfers Job Aid
- Medicare Two Tier Routine Home Care Payment Rate
- Canceling a Hospice Notice of Election
- Hospice Pricer Tool Quick Reference Tool
- How to Bill When the Hospice Face-to-Face is Late from a Previous Benefit Period
- Site of Service Codes for Continuous Home Care and General Inpatient Care Level of Service
- Hospice Payment Rates
- Billing Medicare for a Denial - Condition Code 21
- Reminder on Deleting Revenue Code Line(s) in the Fiscal Intermediary Standard System Direct Data Entry System
Hospice Billing Instructions for Influenza, Pneumococcal and Hepatitis B Vaccines
Medicare covers influenza virus, pneumococcal and hepatitis B vaccines in accordance to coverage requirements, when furnished by a hospice to those beneficiaries who request them, including those who have elected the hospice benefit. As of 10/1/2016, per CR 9052 for claims with an effective date of service on or after 10/1/2016, Medicare hospice providers may bill for vaccine services on institutional claims.
For dates of service on or after 10/1/2016, services for the vaccines provided by a hospice may be billed on an institutional claim to the hospice’s Medicare contractor. Since these services are not part of the Medicare hospice benefit, they must be billed on a separate claim that includes only the vaccines and their administration. For information on coding and payment of vaccine services, please refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 10, Preventive and Screening Services.
CR 7012, as of 1/1/2011 waived all coinsurance and deductibles for certain preventative services, this would include the influenza, pneumococcal and hepatitis B vaccines and their administration are not subject to deductibles and coinsurance.
Vaccine Coverage Requirements
Influenza Virus
In order for Medicare to cover the influenza vaccine, the vaccine must be administered in compliance with any state and local laws, and be administered at the request of the beneficiary. Medicare does not require a physician order to administer the influenza vaccine to a beneficiary. Typically Medicare coverage of the influenza vaccine is one per flu season.
Pneumococcal
Medicare will cover the pneumococcal vaccine when it’s furnished in compliance with any applicable state laws, and is requested by a beneficiary. Medicare does not require a physician order for pneumococcal vaccine. An initial pneumococcal vaccine may be administered to beneficiaries who have never received a pneumococcal vaccine. A different, second pneumococcal vaccine may be administered one year after the first vaccine.
Hepatitis B
For Medicare coverage of the hepatitis B vaccine, the vaccine must be ordered by a doctor of medicine or osteopathy, or by HHAs, SNFs, ESRD facilities, hospital outpatient departments and persons recognized under the incident to physicians’ services provision of law. The beneficiary must also meet one of the criteria in the intermediate or high risk categories for Medicare coverage of the vaccine.
Intermediate Risk Group
- Staff in institutions for the mentally disabled; and
- Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work.
High Risk Group
- ESRD patients
- Hemophiliacs who receive Factor VIII or IX concentrates
- Patients of institutions for the mentally disabled
- Persons who live in the same household as an HBV carrier
- Homosexual men
- Illicit injectable drug abusers
- Persons diagnosed with diabetes mellitus
Below are FAQs regarding billing for influenza and pneumococcal vaccine and roster billing.
Vaccine Billing
- Can we bill a vaccine for a patient on Medicare Care Choice Program?
Answer: Hospices are permitted to bill for vaccines to all Medicare eligible beneficiaries whether or not the beneficiary has elected the hospice benefit. Beneficiaries who have currently not elected the hospice benefit and are enrolled in the Medicare Care Choice Program may receive a vaccine from the hospice provider, and the hospice provider can bill Medicare for the vaccine and its administration.
- Please verify that we can use our hospice NPI when billing claims, and this will not interfere with our regular hospice billing?
Answer: Correct. Billing a hospice vaccine claim should not interfere with the normal hospice claim submission. Keep in mind that for a hospice vaccine claim you can only report revenue code 0771 and/or 0636 with the appropriate HCPCS code or the claim will be returned to the provider. Per the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.5 - Hospice Claims for Vaccine Services, For dates of service on or after 10/1/2016, services for the vaccines provided by a hospice may be billed on an institutional claim to the hospice’s Medicare contractor. Since these services are not part of the Medicare hospice benefit, they must be billed on a separate claim that includes only the vaccines and their administration. For information on coding and payment of vaccine services, see Chapter 18, Section 10 of this manual.
- Can we bill for a vaccine for a hospice patient that is not admitted to our hospice?
Answer: Hospices are permitted to bill for vaccines to all eligible beneficiaries whether or not the beneficiary has elected the hospice benefit.
- If we provide a flu vaccine and bill on a separate claim for the vaccine and the administration, can we bill for a nurse visit on our routine level of care hospice claim?
Answer: When providing a flu vaccine during a routine nurse visit, the hospice will report the nurse visit on their routine hospice claim as instructed per the discipline visit reporting. To constitute a visit, the discipline (as defined by the HCPCS code) must have provided care to the beneficiary. In addition the visit must be reasonable and necessary for the palliation and management of the terminal illness and related conditions described in the patient’s plan of care.
- Can we bill for a vaccine if the beneficiary is a Medicare beneficiary but has not elected hospice?
Answer: Yes. Hospices are permitted to bill for vaccines to all eligible beneficiaries whether or not the beneficiary has elected the hospice benefit.
- When billing for a vaccine should we include all hospice diagnosis on the claim form or only use Z23 to indicate encounter for immunizations?
Answer: You are not required to enter hospice diagnosis on the claim that is billed for vaccines only. You are required to enter the ICD-10 in the primary position that reflects the reason/diagnosis for the administration of vaccine.
- Should we use a condition code 07 on the hospice vaccine claim to indicate this service is not related to the hospice diagnosis?
Answer: No. For hospice vaccine billing claims you are not to report a condition code 07 on the claim.
- We bill our regular hospice claims with a TOB 823. Is it preferred that we bill our vaccine claims with a TOB 821?
Answer: Correct, for billing a hospice vaccine code the preferred frequency code is “1” – admit through discharge, since this claim will be for a service provided during a single month. However, the Medicare system will allow frequency codes 1, 2, 3, 4.
- Will an NPI for referring or attending physician be required on the claim if the beneficiary is on hospice services?
Answer: According to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 25 - Completing and Processing the Form CMS-1450 Data Set, Section 75.7 FL76- Attending Provider Name and Identifiers states, this field is required when claim/encounter contains any services other than nonscheduled transportation services. Therefore, if the beneficiary has an attending physician the NPI number of the attending physician should be put in FL 76. If the beneficiary does not have an attending physician the hospice may use the Medical Directors NPI in this field.
- What patient status code should be reported on a vaccine claim?
Answer: The TOB should be an 8X1 and the patient status code should be “01.”
- Are NDC numbers required on the vaccine claim billed?
Answer: No. The NDC is not required on the claim for vaccine billing.
- Do we need to put an occurrence code 27 on when billing a vaccine claim?
Answer: No, an occurrence code 27 should not be reported on the vaccine claim. The occurrence code 27 is only for routine hospice claims to report the physician certification.
Roster Billing
- When roster billing can you enter the vaccine and administration billing together on the roster bill, or do you have to submit separate roster bills for each revenue code and CPT/HCPCS code?
Answer: Yes. The appropriate vaccine and administration codes can be entered on the roster bill. For example line 1 – the revenue code 0771 (Preventative Care Services-Vaccine Administration) with the appropriate HCPCs code of G0008 – Influenza Vaccine Administration or G0009 - Pneumococcal Vaccine Administration. Line 2 - revenue code 0636 (Pharmacy-Drugs Requiring Detailed coding) with the appropriate HCPCS code for the vaccine that was administered.
- When roster billing, does every beneficiary listed on the roster bill have to receive the same drug?
Answer: Yes. Roster billing is designed for mass immunizers who immunize multiply beneficiaries on the same day with the same vaccine to bill Medicare more efficiently.
- Can Roster Bills be entered electronically?
Answer: Providers may submit roster bills via hardcopy or submitted vie DDE option 87.
- When roster billing does all entries need to be administered on the same day?
Answer: Yes.
- Are there a minimum numbers of beneficiaries that must be entered on a roster bill?
Answer: Yes. For institutional claims only, you must vaccinate at least five beneficiaries on the same date to roster bill.
Reimbursement
- Where can we find the reimbursement rate for vaccines?
Answer: Payment allowances will be published in the CMS influenza vaccine pricing web page. See Season Influenza Vaccine Pricing link below.
- How much do we enter in the charge amount for the vaccine and the administration?
Answer: The MACs cannot instruct providers on the amount to charge for the vaccines or their services. The agency will need to look at their cost for administering the medication and enter a charge amount based on the cost you would charge a beneficiary for this service.