Related Change Request (CR) #: CR 8249
Related CR Release Date: May 2, 2013
Effective Date: November 20, 2012 (For code 90661); January 1, 2013 (For codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033)
Related CR Transmittal #: R2693CP Implementation Date: October 7, 2013
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), carriers and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.
What You Need to Know
This article is based on Change Request (CR) 8249, which provides instructions for payment and Common Working File (CWF) edits to be updated to include influenza virus vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, and Q2033; and hepatitis B virus vaccine code 90739 for claims with dates of service on or after January 1, 2013, but processed on or after October 7, 2013. The CR also provides instructions for payment and Medicare Common Working File (CWF) edits to be updated to include influenza virus vaccine code 90661 for claims with dates of service on or after November 20, 2012, processed on or after October 7, 2013. Make sure that your billing staffs are aware of these updates.
Background
Vaccines that are described by codes 90653, 90685, 90687, 90688, and 90739 are currently pending Food and Drug Administration (FDA) approval. Vaccines that are described by codes 90661, 90672, 90686, and Q2033 have already been approved.
The Centers for Medicare & Medicaid Services (CMS) will notify Medicare contractors once FDA approval is obtained for the vaccines that are described by codes 90653, 90685, 90687, 90688, and 90739. In addition, Medicare contractors are adding Q2033 as an acceptable influenza vaccine code. As a result of CR8249:
- Effective for claims with dates of service on or after January 1, 2013, vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033 will be payable by Medicare.
- Effective for claims with dates of service on or after November 20, 2012, code 90661 will be payable by Medicare.
On professional claims, for dates of service between January 1, 2013 and September 30, 2013, Medicare contractors shall use local pricing guidelines to determine payment rates for influenza virus vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, and Q2033; and hepatitis B virus vaccine code 90739. For dates of service on or after October 1, 2013, Medicare contractors will use Medicare Part B payment limits for these codes. Effective for dates of service between November 20, 2012, and September 30, 2013, contractors shall use local pricing guidelines to determine payment rates for influenza virus vaccine code 90661.
On institutional claims, hospitals (type of bill (TOB) 12X and 13X), skilled nursing facilities (TOB 22X and 23X), home health agencies (TOB 34X), hospital-based renal dialysis facilities (72X), and critical access hospitals (85X), payment will be based on reasonable cost for codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033 with dates on service on or after January 1, 2013. For the same facilities billing code 90661 on or after November 20, 2012, the payment is also based on reasonable cost.
For Indian Health Services (IHS) facilities (including IHS critical access hospitals), comprehensive outpatient rehabilitation facilities, and independent renal dialysis facilities, payment will be based on the lower of the actual charge or 95% of the Average Wholesale Price (AWP).
Medicare contractors shall deny claims for vaccines containing codes 90653, 90685, 90687, 90688, and 90739 if vaccines described by these codes have not obtained approval from the FDA by October 1, 2013. In doing so, they will use:
- Claims Adjustment Reason Code (CARC) 114: Procedure/product not approved by the Food and Drug Administration.
- Remittance Advice Remark Code (RARC) M51: Missing/incomplete/invalid procedure code.
- Group Code: CO
Additional Information
The official instruction, CR 8249, issued to your Medicare contractor regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2693CP.pdf
Last Updated Nov 07, 2013
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