Provider resources

Adult Immunization Resources for Providers

This page provides information, resources, and tools to help support clinicians, including community vaccinators, in delivering and billing Medicare for influenza, pneumococcal, and hepatitis B vaccinations.

Pneumonia and influenza are the fifth leading cause of death in older adults in the U.S. While vaccines are available to prevent and reduce complications from these diseases, their use is suboptimal. African Americans and Hispanics have significantly lower influenza and pneumococcal immunization rates compared to the rest of the population. In 2006, 64% of people 65 and older reported receiving a flu shot in the past 12 months; however, only 46% of non –Hispanic blacks and 45% of Hispanics reported receiving a flu shot, compared with 67% of non-Hispanic whites. While 57% reported having ever received a pneumonia vaccination, only 36% of non-Hispanic blacks and 33% of Hispanics reported ever receiving a pneumonia vaccination, compared with 62% of non-Hispanic whites.

Nursing home residents are especially vulnerable to influenza and pneumonia, and their complications. In October of 2005, CMS began requiring as a condition of participation in the Medicare and Medicaid programs that nursing homes ensure that their residents receive influenza and pneumoccoal vaccinations. As a Medicare condition of participation, the rule requires that long-term care facilities ensure that each resident is:

• offered seasonal influenza immunization annually;
• immunized against influenza unless medically contraindicated or when the resident or the resident's legal representative refuses immunization;
• offered pneumococcal immunization once if there is no history of immunization; and
• immunized against pneumococcal disease unless medically contraindicated or when the resident or the resident's legal representative refuses immunization.

In the case of a vaccine shortage as declared by CDC, state survey agencies would have the discretion not to cite facilities for being out-of­compliance with this requirement.

Coverage

Influenza immunization: Medicare pays for one seasonal influenza immunization each influenza season for all beneficiaries. No coinsurance or co-payment applies to this benefit, and an individual does not have to meet his or her deductible to receive the benefit. Medicare pays separate rates for the administration and cost of the influenza vaccine.

Pneumococcal vaccination: Medicare pays for one pneumococcal vaccination for all beneficiaries. One vaccine at age 65 generally provides coverage for a lifetime, but for some high risk persons, a booster vaccine is needed. Medicare will also pay for the booster vaccination for high risk persons if 5 years have passed since their last vaccination. No coinsurance or co-payment applies to this benefit, and an individual does not have to meet his or her deductible to receive the benefit. Medicare pays separate rates for the administration and cost of the pneumococcal vaccine.  

Hepatitis B vaccination: Medicare pays for hepatitis B vaccinations for individuals considered to be at high or intermediate risk. High risk individuals include persons with end stage renal disease, persons with hemophilia who received Factor VIII or IX concentrates, clients of institutions for the mentally handicapped, homosexual men, persons who live with a person who is a hepatitis B virus carrier, and illicit drug users. Individuals at intermediate risk include staff in institutions for the mentally handicapped, and workers in health care professions who have frequent contact with blood or blood-derived body fluids during their work. The Medicare Part B deductible and coinsurance or co-payment applies to this benefit. Medicare pays separate rates for the administration and cost of the hepatitis B vaccine. A doctor of medicine or osteopathy must order hepatitis B vaccination, but does not have to be present during the delivery of the service unless State law requires his or her presence.

Billing

Two procedure codes need to be on a claim for Medicare reimbursement for each type of vaccination. One code is for cost of the vaccine itself, and the other code is for the cost of the administration of the vaccine. Medicare providers/suppliers may bill for vaccinations the same way they bill for other services using either 1500 or 1450 paper claim forms or electronically.

Individuals and entities interested only in delivering vaccinations must enroll as a Medicare provider. If they are interested in becoming "mass immunizers," which are allowed to provide flu and/or pneumococcal vaccinations to a large number of beneficiaries, they must also enroll and follow the special instructions for mass immunizers. Mass immunizers, also known as community vaccinators, often provide influenza and pneumococcal vaccinations in non-traditional settings, such as churches and grocery stores. Existing providers and suppliers that wish to provide mass immunization services must also obtain a provider specialty number to become mass immunizers. Instructions for enrolling as a traditional Medicare provider or supplier, or as a mass immunizer are contained in the links below.

Mass immunizers have two options for how they bill:

1) Roster billing allows mass immunizers to complete one 1500 or 1450 paper form with the type of vaccination (influenza or pneumococcal) and attach a roster listing the beneficiaries who received that type of vaccination, rather than submitting separate 1500 or 1450 paper claim forms for each individual.

2) Centralized billing allows mass immunizers to submit influenza and pneumococcal vaccination claims to a single carrier for processing regardless of the geographic locality in which the vaccination was delivered. Centralized billing is available for mass immunizers that serve beneficiaries in 3 or more states.

The links below include more details on these billing options, and step-by-step instructions for how to bill Medicare and what forms to use.

*Mass immunizers may not deliver hepatitis B vaccinations. Roster billing and centralized billing are not allowed for hepatitis B vaccinations.

Best practices for improving the delivery of vaccinations

A variety of resources are available that provide information on improving the delivery of vaccinations. Links to these resources are provided below.

One method that the evidence suggests is effective is standing orders programs, which allow nurses and pharmacists, where permitted by state law, to administer vaccinations according to an institution or physician-approved protocol without the need for a physician's examination or direct order. Standing orders are permissible and are encouraged when providing mass immunizations because they make it easier and faster to provide seasonal influenza and pneumococcal vaccinations.

*In October 2002, CMS removed its requirement from the Conditions of Participation that an individual physician must write an order for each seasonal influenza and pneumococcal vaccination given in hospital and long term care settings, and by home health agencies. The links below include information on implementing standing orders programs.

Important resources for providers

Preventive Services Educational Products For Health Care Professionals ~ CMS has developed a variety of educational products for health care professionals to help increase awareness of preventive services covered by Medicare and provide coverage and billing information needed to effectively bill Medicare for preventive services provided to Medicare patients.

The Medicare Learning Network ® (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. The MLN contains information and resources, including "MLN Matters" articles containing guidelines for billing and payment for vaccination services, the 2005 payment rates, and brochures and educational tools that can be downloaded and ordered.

Current Rates for Seasonal Influenza  Vaccine rates can be accessed by going to the Link Inside CMS, " Seasonal Influenza Vaccine Rates"; to determine current administration rates, go the Link Inside CMS, " Seasonal Influenza Administration Rates" using the code, 90471 and specifying your locality.