Preventive Services Guide

Influenza Virus Vaccine and Administration

Influenza (flu) is a contagious respiratory illness caused by the influenza virus that causes mild to severe illness. According to the CDC, millions of people get the flu every year; serious outcomes can result in hospitalization or death. For Medicare billing purposes, the flu season runs from August to July of the following year.

Table of Contents

• Coverage Criteria
• Billing Tips
• Roster Billing
• Mass Immunizers
• Payment Allowances and Effective Dates for the 2024-2025 Flu Season
• Payment Allowances and Effective Dates for the 2023-2024 Flu Season
• Diagnosis Coding
• Cost Sharing
• Reimbursement
• Nonparticipating Providers
• Related Content

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Coverage Criteria

• All Medicare beneficiaries are covered for one flu shot per flu season
  • More than one per season may be covered if medically necessary

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Billing Tips

• The NDC must be included in Loop 2410 LIN segments of the electronic claim, Item 19 on the CMS-1500 paper claim.
  • Each box of vaccine includes the NDC assigned by the manufacturer
  • The NDCs change each influenza season
• Submit single claims electronically unless provider is approved under ASCA exception waiver
  • ASCA exceptions include:
    • Small providers, certain mass immunizers, providers who submit fewer than ten claims per month on an average during a calendar year
• Roster claims may be submitted electronically or on paper
• As a reminder, please review and use the appropriate flu shot code to avoid processing delays and claim denials on the CMS Seasonal Influenza Vaccines Pricing web page.
• Pricing information for the G0008 administration code is located on the Vaccines and Administration Pricing section of the​​​ Fee Schedule Lookup web page under the Admin for Flu/PPV/Hepatitis Fee Schedules section.

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Roster Billing

• Streamlined process for submitting vaccination claims for large groups of individuals
  • All patients have the same service
  • Not used for single patient billing
• Patient roster form includes the following with a single modified CMS-1500 claim form as roster cover document for each facility where the services are rendered:
  • Patients name, address, Medicare number, date of birth and gender
  • Date of service
  • Beneficiary signature or stamped “Signature on File”
  • Providers name and identification number
  • Control number for contractor
• Immunization Roster Billing

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Mass Immunizers

• Must be properly licensed in the state in which they plan to operate flu clinics
• Enrollment is ongoing and completed through the local A/B MAC
• Must use roster billing process and bill to local MAC
• Offer shots to a large number of individuals
• Must accept assignment on the shot and administration
• Annual Influenza Vaccine Season Starts on August 1 and Ends on July 31 of the Following year.

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Payment Allowances and Effective Dates for the 2024-2025 Flu Season

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Payment Allowances and Effective Dates for the 2023-2024 Flu Season

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For the most up to date list of billing codes, payment allowances and effective dates for the 2024-2025 flu season, please see Seasonal Influenza Vaccines Pricing.

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Diagnosis Coding

• ICD-10 Code Z23

Cost Sharing

• Copayment/coinsurance waived
• Deductible waived

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Reimbursement

• Vaccine reimbursed at the nationally established rate
  • 95% of AWP
  • Updated quarterly, available on the CMS website, Seasonal Influenza Vaccines Pricing
  • Rates effective January 1 through December 31 each year

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Nonparticipating Providers

• Nonparticipating providers can choose not to accept assignment of administration
  • Must submit an unassigned claim on beneficiary’s behalf
  • May collect his/her usual charge for administration but cannot collect any fee upfront for vaccine

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Related Content

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 10.1.2 
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.4.2
• MLN^® Educational Tool: Medicare Preventive Services

Revised 10/4/2024