2014 OSAIC Immunization Reimbursement Workshop

1. 2014 OSAIC Immunization ReimbursementWorkshop 8-5-2014 0814 OSAIC Flu Workshop

2. Today’s Presenters • Lori Langevin • Provider Outreach and Education Consultant

3. Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov.

4. No Recording • Attendees/providers are never permitted to record (tape record or any other method) our educational events • This applies to our webinars, teleconferences, live events, and any other type of National Government Services educational event

5. Acronyms • Please access the Acronyms page on the NGSMedicare.com website to view any acronym used within this presentation.

6. Objectives • To provide billing guidelines for the Influenza and Pneumococcal Vaccine Codes as well as the Medicare allowable amounts

7. Agenda • Influenza Vaccine Codes & Medicare Allowable Amounts • Pneumococcal Vaccine Codes & Medicare Allowable Amounts • Roster Billing Process • References • National Government Services Updates

8. Influenza (Flu) Vaccine

9. Coverage • One influenza vaccination per influenza season for all beneficiaries • More than one per season if reasonable and medically necessary • Physician order/presence not required for coverage

10. Influenza Vaccine Codes & Medicare Allowable Amounts • Part B of Medicare pays 100% for the vaccine • Deductible and coinsurance do not apply • Fees subject to change per CMS quarterly drug updates • Current fees effective July 1, 2014 through September 30, 2014 • Drug fee schedule: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2014ASPFiles.html

11. Influenza CPT/HCPCS Codes

12. Influenza CPT/HCPCS Codes

13. Influenza CPT/HCPCS Codes

14. Influenza CPT/HCPCS Codes

15. Influenza CPT/HCPCS Codes

16. Administration & Diagnosis Codes • Administration HCPCS code: • G0008 for influenza virus vaccine seasonal administration • Medicare allowable $26.18 • Effective 1/1/14 • Fee will vary per state - Fee listed is for RI providers • Part B of Medicare pays 100% • Deductible and coinsurance do not apply • Diagnosis codes: • V04.81 for seasonal • V06.6 on claims for influenza vaccine and pneumococcal polysaccharide vaccine (PPV) when purpose of visit was to receive both

17. Billing Guidelines • Paper claims • CMS-1500 (08/05) not accepted on/after April 1, 2014 • CMS-1500 (02/12) accepted on/after January 1, 2014 and required on/after April 1, 2014 • Claims must be submitted on original red & white forms • Visit National Government Services’ Web site for proper paper claims mailing address • http://www.NGSMedicare.com Resources > Contact Us > P.O. Box Mailing Addresses

18. Billing Guidelines • Single claims must be submitted electronically unless provider approved under ASCA exception (waiver) • 10 ASCA (Administrative Simplification Compliance Act) exceptions, including: • Small providers • Certain Mass Immunizers • Providers that submit fewer than 10 claims per month on average during calendar year • Roster claims can be submitted on paper or electronically

19. What Is Roster Billing? • Streamlined process for submitting vaccination claims for large groups of individuals • Both “regular” provider/suppliers & mass immunizers • Cannot use for single patient bills • Cannot bill other services on roster bills

20. Roster Billing Guidelines • Mass immunization roster billers (specialty provider type 73) and centralized billers • Must accept assignment on vaccine and administration • Can only bill for influenza and/or pneumococcal vaccinations • Must submit claims using roster billing process • Separate roster bills must be submitted for influenza and pneumococcal vaccinations

21. Roster Billing Guidelines • Mass Immunizers • Offer vaccinations to large number of individuals • Must be properly licensed in State(s) in which they plan to operate flu clinics • Enrollment is ongoing and completed through local A/B MAC or carrier • Must submit roster bills to local contractor

22. Roster Billing Guidelines • Patient roster form with: • Patient name, address, Health Insurance Claim Number, date of birth and sex (Gender) • Date of service • Beneficiary signature or stamped “Signature on File” • Provider’s Name and Identification Number • Control number for contractor • Single modified CMS-1500 as roster cover document for each facility where services rendered

23. Roster Billing Guidelines

24. Roster Billing Guidelines

25. Roster Billing Guidelines

26. Roster Billing Guidelines

27. Roster Billing Guidelines • Electronic submission of roster claims • Loop and segment information contained in CMS-1500 ANSI X12N 837 Crosswalk • http://www.NGSMedicare.com in Resources tab under “Tools and Materials” link • Mass immunizers required to use HIPAA-adopted ASC X12N 837 claim standard • National Government Services offers low or no-cost software for providers to use • Contact EDI department for more information • 1-877-273-4334, Monday–Friday, 8:00 a.m. - 4:00 p.m. eastern time (ET) 

28. Pneumococcal Vaccine

29. PPV Coverage • Physician order/presence not required by Medicare for coverage • One covered per lifetime for all beneficiaries • Revaccinations • Routine revaccinations are not appropriate • Can be covered if: • High risk patient and at least five years since last covered PPV • Patient unsure of vaccination status within past five years

30. PPV Revaccinations -High Risk Factors • Functional or anatomic asplenia (e.g., from sickle cell disease, splenectomy) • Human Immunodeficiency Virus (HIV) • Leukemia • Lymphoma • Hodgkin’s disease • Multiple myeloma

31. PPV Revaccinations -High Risk Factors • Generalized malignancy • Chronic renal failure • Nephrotic syndrome • Other conditions associated with immunosuppression: • Organ or bone marrow transplantation • Immunosuppressive chemotherapy including long-term corticosteriods

32. Pneumococcal Vaccine Codes & Medicare Allowable Amounts • Part B of Medicare pays 100% for the vaccine • Deductible and coinsurance do not apply • Fees subject to change per CMS quarterly drug updates • Current fees effective July 1, 2014 through September 30, 2014 • Drug fee schedule: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2014ASPFiles.html

33. Pneumococcal Vaccine Billing

34. Administration & Diagnosis Codes • Administration HCPCS code: • G0009 for PPV administration • Medicare allowable $26.18 • Effective 1/1/14 • Fee will vary per state - Fee listed is for RI providers • Part B of Medicare pays 100% • Deductible and coinsurance do not apply • Diagnosis codes: • V03.82 for PPV alone • V06.6 on claims for influenza vaccine and PPV when purpose of visit was to receive both

35. Other Billing Guidelines • Roster billing allowed, using appropriate PPV codes • Must roster bill flu and PPV separately • Medicare does not pay solely for counseling and education for PPV vaccinations

36. General Part A Billing Requirements

37. UB-04 CMS-1450 or Electronic • Use types of bill 13x, 22x, 23x, 34x, 72x, 75x, 83X & 85x • Use revenue code 636 for the vaccines • Same as Part B • Use revenue code 771 for the administration • G0008 • Use appropriate HCPCS coding and diagnosis codes • Same as Part B

38. Pneumococcal (PPV) Vaccine • Vaccine codes: 90732, 90669 & 90670 • Use revenue code 636 • Administration code: G0009 • Use revenue code 771 • ICD-9-CM • V03.82 – PPV vaccination • V06.6 – When the purpose of the visit was to receive both PPV and Flu vaccines

39. Reminders • Roster Billing • Electronically • Direct Data Entry on FISS (Fiscal Intermediary Standard System) • Payment for these vaccines • Reasonable cost basis • For hospitals, home health agencies (HHAs), skilled nursing facilities (SNFs), critical access hospitals (CAHs), and hospital-based renal dialysis facilities (RDF’s) • Payment for comprehensive outpatient rehabilitation facilities (CORFs) and independent RDF’s is based on 95 percent of the average wholesale price (AWP)

40. Contact Information • Provider Contact Center • Part B - 866-837-0241 • Part A - 888-855-4356

41. Resources

42. CMS References • http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html • Coverage of Immunizations • CMS IOM Publication 100-02, Chapter 15, Section 50.4.4.2 • Billing for Immunizations • CMS IOM Publication 100-04, Chapter 18, Section 10 • CMS-1500 (08/05) claim completion requirements • CMS IOM Publication 100-04, Chapter 26

43. CMS Web Site Resources • Seasonal Influenza Vaccines Pricing page • http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html • SE1336: 2013-2014 Influenza (Flu) Resources for Health Care Professionals • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1336.pdf

44. CMS Web Site Resources • MLN Matters Articles • MM8433, “Influenza Vaccine Payment Allowances - Annual Update for 2013-2014 Season” • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8433.pdf • MM8249, “New Influenza Virus and Hepatitis B Virus Vaccine Codes” • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8249.pdf

45. CMS Web Site Resources • Quick Reference Information: Medicare Immunization Billing Chart • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf • SE0580: “Influenza/Flu Season and Available Resources for Providers” • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0580.pdf

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