Reimbursement for Vaccinations
To ensure that a practice will receive adequate payment for vaccines provided in the office-based setting, a clinical practice must investigate whether their third-party payers cover these services, and if so, whether payment is allowed for vaccine drugs and administration.
Medicare Part B currently covers preventive vaccine costs for three conditions:
- Influenza (once per influenza season). Use CPT codes 90630, 90653, 90654, 90655, 90656, 90657, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90688, 90689, or 90756 or Q codes Q2034, Q2035, Q2036, Q2037, or Q2038. They may be linked to ICD-10 diagnosis code Z23 (Encounter for immunization). Payment is 100% of the Medicare allowable reimbursement.
- Pneumococcal conjugate and pneumococcal polysaccharide (once per lifetime, only report one in a single visit). Use CPT codes 90670 or 90732 respectively, linked to diagnosis code Z23. Payment is 100% of the Medicare allowable reimbursement.
- Hepatitis B (for those in medium-risk to high-risk categories). Use CPT codes 90739–90747 linked to diagnosis code Z23. The Part B deductible and coinsurance are waived.
Medicare typically pays for only one influenza vaccination per year. If more than one vaccination is medically necessary (eg, multiple doses are required), then Medicare will pay for those additional vaccinations. If a patient receives the influenza vaccine and a pneumococcal pneumonia virus vaccine during the same visit, use diagnosis code Z23.
The pneumococcal vaccine is paid once per patient in most cases. However, Medicare will reimburse for revaccination if the patient is considered to be at the highest level of risk of a serious pneumococcal infection and for patients likely to have a rapid decrease in pneumococcal antibody levels. At least 5 years must have passed since the most recent dose of this vaccine.
Hepatitis B vaccinations are reimbursed only for Medicare beneficiaries considered to be at highest risk and those most likely to have rapid decreases in antibody levels. Medicare defines the highest-risk patients as those with functional or anatomic asplenia, human immunodeficiency virus (HIV) infection, leukemia, lymphoma, Hodgkin disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression.
Medicare Part B does not cover other immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition (eg, tetanus or exposure to rabies). The ICD-10-CM diagnosis code attached to the vaccine must define the disease or condition.
The prescription drug plan Medicare Part D, however, does cover other preventive vaccines. If the patient has Medicare Part D coverage, it is likely that she has preventive coverage for most vaccines. Travel vaccine coverage will depend on the Part D plan. In states that license pharmacists to provide vaccines, physicians can ask the patient to pur- chase the covered vaccine at the pharmacy and bring it into the office for administration. Alternatively, the physician can supply the vaccine, administer it in the office, and ask the patient for full payment at the time of the service. The patient can then be given a claim form to submit to her Part D plan for reimbursement.
Medicaid reimburses for routine immunizations for covered individuals younger than 21 years. For these individuals, there are two different programs that provide these services:
- Patients aged 19–20 years receive routine immunizations as part of the Early and Periodic Screening, Diagnostic, and Treatment program. Physicians can bill
Medicaid for the vaccines and the administration as a fee for service. This public program for low-income and medically indigent individuals is administered on a state-by-state basis. Thus, the extent of immunization coverage for adults varies state by state.
- Patients 18 years or younger receive vaccinations through the state’s Vaccines for Children (VFC) program. This program is described in the next section.
Vaccines for Children Program
When the Centers for Disease Control and Prevention (CDC) investigated the U.S. mea- sles epidemic of 1989–1991, it found that more than one half of the children who had measles had not been immunized, even though many had seen a health care provider. In response, Congress created the VFC program in 1993.
The VFC program provides free vaccines to doctors who serve eligible children. It is administered at the national level by the CDC through the National Immunization Program. The CDC contracts with vaccine manufacturers to buy vaccines at reduced rates. Eligible children are those who meet the following criteria:
- Are eligible for Medicaid
- Are 18 years or younger
- Have no health insurance
- Are Native American or Alaska Native
- Have health insurance but no immunization coverage. In these cases, these chil- dren must go to a federally qualified health center or rural health clinic to receive their immunizations.
Vaccinations are provided for the following diseases:
- Haemophilus influenzae type b
- Hepatitis A
- Hepatitis B
- Human papillomavirus
- Meningococcal disease
- Pertussis (whooping cough)
- Pneumococcal disease
Any physician or physician practice can become a VFC provider. First, contact a state or territory VFC program coordinator. A Provider Enrollment Package will be mailed to the health care provider. After submission of this packet, the office will have a site visit. During this visit, a representative from the program will review the administrative requirements of the program and the proper storage and handling of vaccines with physicians and staff.
Because VFC vaccines are provided free of charge to the practice, an office cannot charge the patient for the vaccine product. However, an administrative fee can be charged. Each state sets a maximum fee that physicians can charge for administering a VFC vaccine. If the patient has no health insurance, a VFC health care provider cannot refuse to administer a recommended vaccine because a patient is unable to pay the administration fee. However, the obstetrician–gynecologist or other health care provider can accept whatever the patient can afford to pay. The administration fee for Medicaid patients is billed to the Medicaid plan. For more information on the VFC program, visit the CDC website, www.cdc.gov/vaccines/programs/vfc/index.html.
Patients can be enrolled in a variety of private or employer-provided commercial health insurance programs. Coverage for immunizations will vary from plan to plan. Some plans may offer no coverage for preventive medicine services. For patients covered
by these plans, it is important to inform them that they will have to bear the costs of immunizations “out of pocket.” For patients who have coverage, it is very important to track payments to verify that the reimbursement received covers the cost of the vaccine product and other associated costs. Clinical practices must contact their patients’ insur- ance plans to verify coverage for preventive and medically indicated vaccines and their administration.
Third-party payers may or may not reimburse for vaccinations provided at the time of a covered evaluation and management (E/M) service. Some third-party payers will disallow the vaccine administration codes at the time of an E/M service unless the E/M service is documented as separate and significant. (See the section “Coding Examples” for additional information on when it is appropriate to bill an E/M service with vaccine administration.)
The Initial Reproductive Health Visit
The American College of Obstetricians and Gynecologists recommends that a girl’s first visit to her obstetrician–gynecologist take place between the ages of 13 years and 15 years. This visit is designed to provide health guidance, appropriate screening, and preventive health services. It is an excellent opportunity to discuss ongoing immunization status as well as the new recommendations for the human papillomavirus (HPV) vaccine; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine; and menin- gococcal vaccine. The CPT code 99384 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interven- tions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent [age 12–17 years]) is used for a preventive visit for a new patient aged 12–17 years. The CPT code 99394 (Periodic comprehensive preventive medicine reevaluation and man- agement of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent [age 12–17 years]) is used for a preventive visit for an established patient in the same age range.
It may be appropriate to offer and administer indicated vaccines during these initial reproductive health visits. If these services are performed, the physician also should code for the appropriate vaccine administration code(s) and the appropriate vaccine product code(s) as well as the preventive service.
Note: ICD-10-CM contains a single code for immunizations (Z23—Encounter for immunization). The CPT or Health- care Common Procedure Coding System (HCPCS) codes linked to diagnosis code Z23 will identify the specific immunizations administered.