Hospice Billing Instructions for Influenza, Pneumococcal and Hepatitis B Vaccines

Medicare covers influenza virus, pneumococcal and hepatitis B vaccines in accordance with coverage requirements, when furnished by a hospice to those beneficiaries who request them, including those who have elected the hospice benefit.

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.

The influenza, pneumococcal and hepatitis B vaccines and their administration are not subject to deductibles and coinsurance.

Vaccine Coverage Requirements

Influenza Virus

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 once 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 use our hospice NPI when billing claims? Will this interfere with our regular hospice billing?

Answer: 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.
When billing for a vaccine should we include all hospice diagnoses on the claim form or only use Z23 to indicate encounter for immunizations?

Answer: You are not required to enter hospice diagnoses 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.
Should we bill our vaccine claims with a TOB 821?

Answer: Yes. When billing a hospice vaccine claim 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.
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 an occurrence code 27 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, do all entries need to be administered on the same day?

Answer: Yes.
Are there a minimum number 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 Seasonal 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.