Influenza Virus and the Pneumoccocal Vaccines Payment Allowances
Provider Types Affected
Physicians, non-physician practitioners, providers and suppliers billing Medicare contractors (Part A/B Medicare Administrative Contractors (A/B MACs), Fiscal Intermediaries (FIs) and carriers for the influenza and pneumoccocal vaccines.
Background
This article and related change request (CR) 5365 provide the payment allowances for the following influenza virus vaccines: CPT codes 90655, 90656, 90657, and 90658 as well as the pneumoccocal vaccine (CPT 90732) when payment is based on 95 percent of the Average Wholesale Price (AWP).
Key Points
- Effective September 1, 2006, the Medicare Part B payment allowance for CPT 90655 is $15.377.
- Effective September 1, 2006, the Medicare Part B payment allowance for CPT 90656 is $16.574.
- Effective September 1, 2006, the Medicare Part B payment allowance for CPT 90657 is $6.312.
- Effective September 1, 2006, the Medicare Part B payment allowance for CPT 90658 is $12.624.
- Effective September 1, 2006, the Medicare Part B payment allowance for CPT 90732 is $27.028.
- Annual Part B deductible and coinsurance amounts do not apply to these services.
- All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination and the pneumoccocal vaccination must take assignment on the claim for the vaccine.
- Note that your carrier or FI may also cover CPT 90660 (FluMist, a nasal influenza vaccine) if they determine its use is medically reasonable and necessary for the beneficiary.
- Please take note of this pricing information to ensure accurate claims processing. Your carrier or FI will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, they will adjust claims brought to their attention.
Implementation
While the implementation of these rates will occur on January 22, 2007, the rates apply to dates of service on or after September 1, 2006.
Additional Information
To view CR 5365, the official instruction issued to your Medicare FI, Carrier or A/B MAC on this issue, visit http://www.cms.hhs.gov/Transmittals/downloads/R256OTN.pdf on the CMS website.
If you have any questions, please contact your state's Provider Contact Center.
MLN Matters MM5365
CPT five digit codes, nomenclature and other data only are copyright 2005 American Medical Association. All rights reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein.
