Entities submitting roster claims to carriers/AB MACs must complete the following blocks on a single modified Form CMS-1500 (08-05) , which serves as the cover document for the roster for each facility where services are furnished. In order for carriers/AB MACs to reimburse by correct payment locality, a separate Form CMS-1500 (08-05) must be used for each different facility or physical location where services are furnished.
|Item 1:||An X in the Medicare block|
|Item 2:||(Patient’s Name): “SEE ATTACHED ROSTER”|
|Item 11:||(Insured’s Policy Group or FECA Number): “NONE”|
|Item 20:||(Outside Lab?): An “X” in the NO block|
|Item 21:||(Diagnosis or Nature of Illness):Line 1: Choose appropriate diagnosis code:V04.81 – Influenza VaccineV03.82 – Pneumococcal Polysaccharide Vaccine (PPV)V05.3 – Hepatitis B VaccineV06.6 – Purpose of visit was to receive both PPV and Flu vaccines|
|Item 24B:||(Place of Service (POS)):Line 1: “60”Line 2: “60”NOTE: POS Code “60” must be used for roster billing.|
|Item 24D:||(Procedures, Services or Supplies):Line 1:Influenza Virus vaccine: “Select appropriate influenza virus vaccine code”orPneumococcal vaccine: “90732”Line 2:Influenza Virus Vaccine Administration: “G0008″OrPneumococcal vaccine Administration: “G0009”|
|Item 24E:||(Diagnosis Code):Lines 1 and 2: “1”|
|Item 24F:||($ Charges): The entity must enter the charge for each listed service. If the entity is not charging for the vaccine or its administration, it should enter 0.00 or “NC” (no charge) on the appropriate line for that item. If your system is unable to accept a line item charge of 0.00 for an immunization service, do not key the line item. Likewise, electronic media claim (EMC) billers should submit line items for free immunization services on EMC pneumococcal or influenza virus vaccine claims only if your system is able to accept them.|
|Item 27:||(Accept Assignment): An “X” in the YES block.|
|Item 29:||(Amount Paid): “$0.00”|
|Item 31:||(Signature of Physician or Supplier): The entity’s representative must sign the modified Form CMS-1500 (08-05).|
|Item 32:||Enter the name, address, and ZIP Code of the location where the service was provided (including centralized billers).|
|Item32a:||Enter the NPI of the service facility as soon as it is available. The NPI may be reported on the Form CMS-1500 (08-05) as early as October 1, 2006|
|Item 33:||(Physician’s, Supplier’s Billing Name): The entity must complete this item to include the Provider Identification Number (not the Unique Physician Identification Number) or NPI when required.|
|Item 33a:||Effective May 23, 2007, and later, enter the NPI of the billing provider or group. (The NPI may be reported on the Form CMS-1500 (08-05) as early as October 1, 2006.)|
NOTE: A stamped “signature on file” qualifies as an actual signature on a roster claim form if the provider has a signed authorization on file to bill Medicare for services rendered. In this situation, the provider is not required to obtain the patient signature on the roster, but instead has the option of reporting signature on file in lieu of obtaining the patient’s actual signature.
The pneumococcal roster must contain the following language to be used by providers as a precaution to alert beneficiaries prior to administering the pneumococcal vaccination.
WARNING: Beneficiaries must be asked if they have received a pneumococcal vaccination.
- Rely on patient’s memory to determine prior vaccination status.
- If patients are uncertain whether they have been vaccinated within the past 5 years, administer the vaccine.
- If patients are certain that they have been vaccinated within the past 5 years, do not revaccinate.
Refer to the Medicare Claims Processing Manual, Chapter 18, section 10.3 , Preventive and Screening Services for additional information.