Influenza vaccine payments amounts released for 2013-2014

September 18th, 2013 - Scott Kraft   
Categories:   Preventive Medicine Service  

CMS has released the coding and payment information for the 2013-2014 flu vaccine season. As flu season kicks into overdrive, it seems like a good time to review payment rules for the flu shot.

Most insurance payers will cover one flu shot per flu season. The Affordable Care Act (ACA) requires that payers cover a flu vaccination without any out-of-pocket expense to the patient when done by an in-network provider.

The annual flu vaccine is recommended by the CDC for anybody aged 6 months and above. High risk groups include pregnant women, those age 6 months through 4 years or 50 and above, people with medical conditions such as asthma, diabetes or chronic lung disease. Caregivers and those who live with someone in a high-risk group are also advised to get vaccinated.

The flu vaccine and its administration are two separate codes that are typically not bundled for payment purposes into any other service delivered in a physician practice on the same date of service.

The administration of the vaccine is billed with HCPCS code G0008, for which Medicare makes a national average payment of $25.86. The administration payment is under the Medicare Physician Fee Schedule and subject to adjustment due to locality and any 2014 payment changes effective Jan. 1.

Here are the codes and payment amounts from Medicare for the 2013-2014 season, defined as Aug. 1, 2013-July 31, 2014. Use V04.81 as the diagnosis code on the claim. Remember that Medicare pays for drugs three places past the decimal point and will round up or down:
  • 90654: $18.918
  • 90655: $17.243
  • 90656: $12.398
  • 90657: $6.022
  • 90661: Pending
  • 90685: $23.228
  • 90686: $19.409
  • 90687: Pending
  • 90688: Pending
  • Q2035: $11.543
  • Q2036: $8.579
  • Q2037: $14.963
  • Q2038: $12.044
  • Q2039: Locally determined

Medicare payment for 90661 and 90687-90668 will be released then the vaccines are approved, CMS says. Keep in mind that private payers may reimburse at different amounts. In order to determine which code to bill for which vaccine, we’ve attached a printable table from the Immunization Action Coalition showing which codes to choose based on the vaccine manufacturer and the size of the dosage. Note that for a limited number of vaccines, coding will be different for Medicare.


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