Also, we would like to update you that effective from the date of service 01/01/2011, CPT 90658 would not be paid by Medicare and it is replaced with the below mentioned codes.
Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)
Effective for claims with dates of service on or after January 1, 2011, the following CPT code will no longer be payable for Medicare:
CPT 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use.
Medicare update on influenza vaccine - CPT Q2035, Q2036, Q2037, Q2038
We would like to inform that effective from the dates of services Jan 1, 2011 CPT 90658 (Influenza vaccine) would not be paid by Medicare and replaced with the below mentioned codes.
Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified
Flu CPT code update from wellcare 90655, 90656, 90657
Wellcare – Flu Vaccination Season 2012-2013
This communication provides you with important information regarding the 2012-2013 flu season (September 1,2012 through April 15,2013)and Wellcare/HealthEase (The Plan's) flu vaccination claim administration guidelines.
These guidelines do not apply for claims submitted outside of the dates of service September 1,2012 through April 15, 2013.
Vaccination recommendations for this season have not changed and still include all persons ages 6 months and older.
The Plan offers FREE flu vaccinations for its members. Please encourage our members to receive the flu vaccination at any of the following locations:
Physician Offices – Member co-payments are not required for this service
Non-Capitated Providers – If you are a Non-Capitated Provider, you will be reimbursed for administering the flu vaccine based upon your contractual agreement with the Plan, medical group and/or IPA.
Capitated Providers
a. Capitated Providers who receive the vaccine through Vaccines for Children (VFC) should bill one of the following CPT codes to receive payment for only the administration of the flu vaccine:
90655 – Influenza virus vaccine, children 6-35 ,months (preservative free)
90656 – Influenza virus vaccine, individuals 3 years and older (preservative free)
90657 – Influenza virus vaccine, children 6-35 months
90662 – Influenza virus vaccine, individuals 3 years and older
b. Capitated Providers who do NOT receive the vaccine through VFC should beill code G0008 to receive reimbursement for the administration of the flu vaccine and ALSO bill one of the following CPT codes to receive payment for the vaccine:
90655 – Influenza virus vaccine, children 6-35 ,months (preservative free)
90656 – Influenza virus vaccine, individuals 3 years and older (preservative free)
90657 – Influenza virus vaccine, children 6-35 months
90662 – Influenza virus vaccine, individuals 3 years and older
Participating Pharmacies – Members can receive a FREE flu vaccine at local participating pharmacies. For information or to find a nearby location, member should call the Customer Service number on the back of their member ID card. With a Plan ID card, members are eligible for a FREE flu vaccine with no co-payment.
Community-based Clinics – Mollen immunization clinics are held throughout the community at local retail pharmacies and/or community centers. To locate a Mollen imminization clininc, members should call 1-877-279-3588, Option 7 or log on to www.flushotsusa.com to find a clinic scheduled near their home or work address.
Members who receive their flu vaccine at a location other than a participating provider, pharmacy location or community-based clinic must submit a detailed receipt with their bill. The Plan will reimburse members up to a maximum of our in-network cost of $25.00 for the administration of the flu vaccine.
Members should submit a detailed receipt with their full name, current address, date of birth, Plan ID#, date of service and amount paid; along with proof of payment (cancelled check, credit card receipt, etc.) to the following address:
Wellcare Health Plans
Attn: Reimbursement Department
P O Box 31577
Tampa, FL 33634-3577
Provider Services contact at 1-888-888-9355 (Medicare), 1-800-278-0656 (HealthEase), 1-800-278-8178 (HealthEase Kids), 1-866-334-7927 (Staywell), 1-866-698-5437(Staywell Kids) or (TTY/TDD (all plans) – 877-247-6272).
Product Product Description Carton NDCa Unit-of-Use (vial or syringe) NDCa CPT®b Code Administration CPT Code without Counseling through 18 Years of Agec ,and All Patients Over 18 Years of Age Administration CPT Code withCounseling through 18 Years of Age Typical ICD-9 Code(s) (Dates of Service through 10/1/2015) d Typical ICD-10-CM Code (Dates ofService On and After 10/1/2015) d ActHIB® Haemophilus b Conjugate Vaccine (Tetanus Toxoid Conjugate) 49281-0545-05 49281-0547-58 (powder) 9281-0546-05 (diluent) 90648 90471/90472 90460 - 1 unit V03.81 Z23 Adacel ® Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine Adsorbed 49281-0400-10 49281-0400-15 49281-0400-58 49281-0400-88 90715 90471/90472 90460 - 1 unit 90461 - 2 units V06.1e Z23e
DAPTACEL® Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed 49281-0286-10 49281-0286-58 90700 90471/90472 90460 - 1 unit 90461 - 2 units
V06.1 Z23 Diphtheria and Tetanus Diphtheria and Tetanus Toxoids Adsorbed (DT) 49281-0225-10 49281-0225-58 90702 90471/90472
90460 - 1 unit
90461 - 1 unit V06.5e Z23
Fluzone® Influenza Vaccine 49281-0396-15f 49281-0396-78f 90657 (0.25 mL dose)
90471/90472 G0008 (Medicareg ) 90460 - 1 unit V04.81h,i V06.6h,i Z23
Medicare and Influenza Vaccine
Medicare Part B covers influenza vaccine and its administration, but has some specific coding requirements:
Vaccine Coding - Code the vaccine using the traditional CPT code that identiies the product you are using. Remember that if you are billing for a 0.5 mL dose of trivalent influenza vaccine in a multidose vial, Medicare has developed a “Q-code” set that is specific to the brand of vaccine used, and they will not pay a claim billed with the traditional CPT code 90658.
As noted on the inside of this brochure, Fluzone vaccine (0.5 mL, trivalent, multidose vial) is billed with Q2038. As of the 2015/2016 influenza season, Q codes were not implemented for Quadrivalent vaccines, and the traditional CPT codes should be used.
Administration Coding – Medicare does not accept the traditional administration code for influenza vaccine, and G0008 must be used. This is regardless of the patient age or whether counseling is performed. Medicare will not pay for vaccine administration if it is billed with any code other than G0008.
Medicaid Managed Care – Check with your plans for coding requirements that may differ from what is noted here.
Seasonal Influenza Virus Vaccine Administration Code:
G0008
Diagnosis Code: Z23
90630 – Influenza split virus vaccine, quadrivalent, preservative free, for intradermal use
90653 – Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use
90654 – Influenza virus vaccine, split virus, preservative-free, for intradermal use
90655 – Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6–35 months of age, for intramuscular use
90656 – Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
90657 – Influenza virus vaccine, trivalent, split virus, when administered to children 6–35 months of age, for intramuscular use
90660 – Influenza virus vaccine, live, for intranasal use
90661 – Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
90672 – Influenza virus vaccine, quadrivalent, live, for intranasal use
90673 – Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use
90685 – Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6–35 months of age, for intramuscular use
90686 – Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use
90687 – Influenza virus vaccine, quadrivalent, split virus, when administered to children 6–35 months of age, for intramuscular use
90688 – Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Q2035 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
Q2038 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified)
HCPCS
Code Short Description Long Description
Q2035 Afluria vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 Flulaval vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 Fluvirin vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
Q2038 Fluzone vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 NOS flu vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)
Take Note: CPT 90658 describes the regular dose vaccine that is supplied in a multidose vial for use in patients over 3 years of age. For dates of service on or after October 1, 2010, HCPCS codes Q2035, Q2036, Q2037, Q2038 and Q2039 (as listed in the table above) will replace the CPT code 90658 for Medicare payment purposes during the 2010 – 2011 influenza season.
However, these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized.
This instruction does not affect any other CPT codes. It is very important to distinguish between the various CPT and HCPCS codes which describe the different formulations of the influenza vaccines (i.e. pediatric dose, regular dose, high dose, preservative free, etc.).
As a reference, the quarterly Part B drug pricing files includes a set of National Drug Code (NDC) to HCPCS crosswalks available online at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part- Drugs/McrPartBDrugAvgSalesPrice/index.html on the Centers for Medicare &Medicaid Services (CMS) website.
HCPCS Code Allowance
Q2036 $8.784
Q2037 $13.253
Q2038 $12.593
No national payment limits are available for Q2035 and Q2039. The payment limits for these two codes will be determined by the local claims processing contractor.
For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.
What’s New?
Effective for dates of service on or after October 1, 2010, Healthcare Common Procedure Coding System (HCPCS) codes Q2035, Q2036, Q2037, Q2038, and Q2039 will replace the Current Procedural Terminology (CPT) code 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) for Medicare payment purposes during the 2010-2011 influenza season; however, these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized.
Since Medicare reimbursement rates change periodically, providers are encouraged to enroll in a relevant CMS electronic mailing list at http://www.cms.gov/ AboutWebsite/20_EmailUpdates.asp for the latest updates.
Seasonal Influenza Virus Vaccine
Administration Code: G0008
Diagnosis Code: V04.81
90655 – Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use
90656 – Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
90657 – Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use
90658 until 12/31/2010 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Q2035 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirun)
Q2038 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)
90660 – Influenza virus vaccine, live, for intranasal use
90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
Influenza Vaccine
Codes 90630, 90653 - 90658, 90660 - 90662, 90664, 90672, 90673,90685 - 90688 Q2034-Q2038
* Use the proper CPT code based on the vaccine type administered.
* For state-supplied vaccine, bill the CPT code.
* For non-state-supplied vaccine, bill the CPT code and append the -22 modifier
DISCLAIMER
The billing and coding information contained in this document is presented as a resource and guide to billing and coding for FLUCELVAX® (Influenza Vaccine) and FLUVIRIN® (Influenza Virus Vaccine). Billing and coding information is gathered from several sources and is subject to change without notice.
While every effort is made to ensure the accuracy of this information, appropriate billing and coding for healthcare services is the provider’s responsibility and should always be based on the patient’s clinical condition, services provided, and payer guidelines.
VACCINE CODES
FLUCELVAX is coded using Current Procedural Terminology (CPT®) code 90661, and FLUVIRIN is coded using CPT codes 90656 and Q2037. These are the Healthcare Common Procedure Coding System (HCPCS) codes approved for use by the Centers for Medicare and Medicaid Services.
Medicaid plans and some payers may also require use of the National Drug Code (NDC) code. Please check with your payer, as specific requirements may vary.
Transmittal 815, dated November 19, 2010 is being rescinded and replaced by Transmittal 884 Dated
April 22, 2011. This CR is being corrected to update the price for HCPCS code Q2036 to $8.784. The effective date for this price will be made retroactive to October 1, 2010. All other information remains the same.
SUBJECT: New HCPCS Q-codes for 2010-2011 Seasonal Influenza Vaccines
I. SUMMARY OF CHANGES: In response to a program need to establish separate billing codes for each brand-name influenza vaccine product under CPT code 90658, this instruction describes the process for updating the new specific HCPCS codes and their payment allowances for Medicare during the 2010-2011 influenza season.
Number Requirement Responsibility (place an “X” in each applicable column)
A / B M ACD M E M A C F I C A R R I E R R H H I SharedSystem Maintainers OTHER FI S S M C S VM S C W F 7234.1 ontractors shall accept the following new codes: Q2035, Q2036, Q2037, Q2038 and Q2039 as valid HCPCS codes for dates of service on or after October 1, 2010. These codes will be included in the January 2011 annual HCPCS file update.
X X X X X X COBC IOCE 7234.2 Contractors shall use the MPFSDB Procedure Status Indicator “I” for 90658 effective for dates of service after December 31, 2010. This change will be updated on the January 2011 MPFSDB. X X X X X
7234.3 Contractors shall manually add HCPCS codes Q2035, Q2036, Q2037, Q2038 and Q2039 to the procedure code file, the 2010 MPFSDB, or appropriate on-line files to reflect an effective date of October 1, 2010. This change will also be updated on the January 2011 MPFSDB.
The payment indicators for Q2035, Q2036, Q2037, Q2038 and Q2039 are listed below:
Procedure Status: X WRVU: 0.00 Transitional Non-Facility PE RVU: 0.00 Fully Implemented Non-Facility PE RVU: 0.00
Transitional Facility PE RVU: 0.00 Fully Implemented Facility PE RVU: 0.00 Malpractice RVU: 0.00 PC/TC: Site of Service: Global Surgery: XXX Multiple Procedure Indicator: Bilateral Surgery Indicator: Assistant at Surgery Indicator: Co-Surgery Indicator: Team Surgery Indicator: Physician Supervision Diagnostic Indicator:
Manufacturer Trade Name (vaccine abbreviation)1 How Supplied MercuryContent (µg Hg/0.5mL) Age Group Vaccine Product Billing Code2 CPT Medicare3
AstraZeneca FluMist4 (LAIV4) 0.2 mL (single-use nasal spray) 0 2 through 49 years 90672 90672
GlaxoSmithKline Fluarix (IIV4) 0.5 mL (single-dose syringe) 0 3 years & older 90686 90686 ID Biomedical Corp. of Quebec, a subsidiary of GlaxoSmithKline FluLaval (IIV4) 0.5 mL (single-dose syringe) 0 6 months & older 90686 90686 5.0 mL (multi-dose vial) <25 6 months & older 90688 90688 Protein Sciences Corp. Flublok (RIV3) 0.5 mL (single-dose vial) 0 18 years & older 90673 90673 Sanofi Pasteur, Inc.
Fluzone (IIV4)
0.25 mL (single-dose syringe) 0 6 through 35 months 90685 90685
0.5 mL (single-dose syringe) 0 3 years & older 90686 90686
0.5 mL (single-dose vial) 0 3 years & older 90686 90686
5.0 mL (multi-dose vial) 25 6 through 35 months 90687 90687
5.0 mL (multi-dose vial) 25 3 years & older 90688 90688
Fluzone High-Dose (IIV3-HD) 0.5 mL (single-dose syringe) 0 65 years & older 90662 90662
Fluzone Intradermal (IIV4-ID) 0.1 mL (single-dose microinjection system) 0 18 through 64 years 90630 90630 Seqirus (formerly Novartis influenza vaccines and bioCSL) Afluria (IIV3) 0.5 mL (single-dose syringe) 0 9 years & older5,6 90656 90656 5.0 mL (multi-dose vial) 24.5 90658 Q2035
Product Product Description Carton NDCa Unit-of-Use (vial or syringe) NDCa CPT®b Code Administration CPT Code without Counseling through 18 Years of Agec ,and All Patients Over 18 Years of Age Administration CPT Code withCounseling through 18 Years of Age Typical ICD-9 Code(s) (Dates of Service through 10/1/2015) d Typical ICD-10-CM Code (Dates ofService On and After 10/1/2015) d ActHIB® Haemophilus b Conjugate Vaccine (Tetanus Toxoid Conjugate) 49281-0545-05 49281-0547-58 (powder) 9281-0546-05 (diluent) 90648 90471/90472 90460 - 1 unit V03.81 Z23 Adacel ® Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine Adsorbed 49281-0400-10 49281-0400-15 49281-0400-58 49281-0400-88 90715 90471/90472 90460 - 1 unit 90461 - 2 units V06.1e Z23e
DAPTACEL® Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed 49281-0286-10 49281-0286-58 90700 90471/90472 90460 - 1 unit 90461 - 2 units
V06.1 Z23 Diphtheria and Tetanus Diphtheria and Tetanus Toxoids Adsorbed (DT) 49281-0225-10 49281-0225-58 90702 90471/90472
90460 - 1 unit
90461 - 1 unit V06.5e Z23
Fluzone® Influenza Vaccine 49281-0396-15f 49281-0396-78f 90657 (0.25 mL dose)
90471/90472 G0008 (Medicareg ) 90460 - 1 unit V04.81h,i V06.6h,i Z23
Medicare and Influenza Vaccine
Medicare Part B covers influenza vaccine and its administration, but has some specific coding requirements:
Vaccine Coding - Code the vaccine using the traditional CPT code that identiies the product you are using. Remember that if you are billing for a 0.5 mL dose of trivalent influenza vaccine in a multidose vial, Medicare has developed a “Q-code” set that is specific to the brand of vaccine used, and they will not pay a claim billed with the traditional CPT code 90658.
As noted on the inside of this brochure, Fluzone vaccine (0.5 mL, trivalent, multidose vial) is billed with Q2038. As of the 2015/2016 influenza season, Q codes were not implemented for Quadrivalent vaccines, and the traditional CPT codes should be used.
Administration Coding – Medicare does not accept the traditional administration code for influenza vaccine, and G0008 must be used. This is regardless of the patient age or whether counseling is performed. Medicare will not pay for vaccine administration if it is billed with any code other than G0008.
Medicaid Managed Care – Check with your plans for coding requirements that may differ from what is noted here.
Seasonal Influenza Virus Vaccine Administration Code:
G0008
Diagnosis Code: Z23
90630 – Influenza split virus vaccine, quadrivalent, preservative free, for intradermal use
90653 – Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use
90654 – Influenza virus vaccine, split virus, preservative-free, for intradermal use
90655 – Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6–35 months of age, for intramuscular use
90656 – Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
90657 – Influenza virus vaccine, trivalent, split virus, when administered to children 6–35 months of age, for intramuscular use
90660 – Influenza virus vaccine, live, for intranasal use
90661 – Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
90672 – Influenza virus vaccine, quadrivalent, live, for intranasal use
90673 – Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use
90685 – Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6–35 months of age, for intramuscular use
90686 – Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use
90687 – Influenza virus vaccine, quadrivalent, split virus, when administered to children 6–35 months of age, for intramuscular use
90688 – Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Q2035 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
Q2038 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified)
HCPCS
Code Short Description Long Description
Q2035 Afluria vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 Flulaval vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 Fluvirin vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
Q2038 Fluzone vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 NOS flu vacc, 3 yrs & >, im Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)
Take Note: CPT 90658 describes the regular dose vaccine that is supplied in a multidose vial for use in patients over 3 years of age. For dates of service on or after October 1, 2010, HCPCS codes Q2035, Q2036, Q2037, Q2038 and Q2039 (as listed in the table above) will replace the CPT code 90658 for Medicare payment purposes during the 2010 – 2011 influenza season.
However, these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized.
This instruction does not affect any other CPT codes. It is very important to distinguish between the various CPT and HCPCS codes which describe the different formulations of the influenza vaccines (i.e. pediatric dose, regular dose, high dose, preservative free, etc.).
As a reference, the quarterly Part B drug pricing files includes a set of National Drug Code (NDC) to HCPCS crosswalks available online at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part- Drugs/McrPartBDrugAvgSalesPrice/index.html on the Centers for Medicare &Medicaid Services (CMS) website.
HCPCS Code Allowance
Q2036 $8.784
Q2037 $13.253
Q2038 $12.593
No national payment limits are available for Q2035 and Q2039. The payment limits for these two codes will be determined by the local claims processing contractor.
For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.
What’s New?
Effective for dates of service on or after October 1, 2010, Healthcare Common Procedure Coding System (HCPCS) codes Q2035, Q2036, Q2037, Q2038, and Q2039 will replace the Current Procedural Terminology (CPT) code 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) for Medicare payment purposes during the 2010-2011 influenza season; however, these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized.
Since Medicare reimbursement rates change periodically, providers are encouraged to enroll in a relevant CMS electronic mailing list at http://www.cms.gov/ AboutWebsite/20_EmailUpdates.asp for the latest updates.
Seasonal Influenza Virus Vaccine
Administration Code: G0008
Diagnosis Code: V04.81
90655 – Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use
90656 – Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
90657 – Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use
90658 until 12/31/2010 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Q2035 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirun)
Q2038 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 beginning 1/1/2011 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)
90660 – Influenza virus vaccine, live, for intranasal use
90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
Influenza Vaccine
Codes 90630, 90653 - 90658, 90660 - 90662, 90664, 90672, 90673,90685 - 90688 Q2034-Q2038
* Use the proper CPT code based on the vaccine type administered.
* For state-supplied vaccine, bill the CPT code.
* For non-state-supplied vaccine, bill the CPT code and append the -22 modifier
DISCLAIMER
The billing and coding information contained in this document is presented as a resource and guide to billing and coding for FLUCELVAX® (Influenza Vaccine) and FLUVIRIN® (Influenza Virus Vaccine). Billing and coding information is gathered from several sources and is subject to change without notice.
While every effort is made to ensure the accuracy of this information, appropriate billing and coding for healthcare services is the provider’s responsibility and should always be based on the patient’s clinical condition, services provided, and payer guidelines.
VACCINE CODES
FLUCELVAX is coded using Current Procedural Terminology (CPT®) code 90661, and FLUVIRIN is coded using CPT codes 90656 and Q2037. These are the Healthcare Common Procedure Coding System (HCPCS) codes approved for use by the Centers for Medicare and Medicaid Services.
Medicaid plans and some payers may also require use of the National Drug Code (NDC) code. Please check with your payer, as specific requirements may vary.
Transmittal 815, dated November 19, 2010 is being rescinded and replaced by Transmittal 884 Dated
April 22, 2011. This CR is being corrected to update the price for HCPCS code Q2036 to $8.784. The effective date for this price will be made retroactive to October 1, 2010. All other information remains the same.
SUBJECT: New HCPCS Q-codes for 2010-2011 Seasonal Influenza Vaccines
I. SUMMARY OF CHANGES: In response to a program need to establish separate billing codes for each brand-name influenza vaccine product under CPT code 90658, this instruction describes the process for updating the new specific HCPCS codes and their payment allowances for Medicare during the 2010-2011 influenza season.
Number Requirement Responsibility (place an “X” in each applicable column)
A / B M ACD M E M A C F I C A R R I E R R H H I SharedSystem Maintainers OTHER FI S S M C S VM S C W F 7234.1 ontractors shall accept the following new codes: Q2035, Q2036, Q2037, Q2038 and Q2039 as valid HCPCS codes for dates of service on or after October 1, 2010. These codes will be included in the January 2011 annual HCPCS file update.
X X X X X X COBC IOCE 7234.2 Contractors shall use the MPFSDB Procedure Status Indicator “I” for 90658 effective for dates of service after December 31, 2010. This change will be updated on the January 2011 MPFSDB. X X X X X
7234.3 Contractors shall manually add HCPCS codes Q2035, Q2036, Q2037, Q2038 and Q2039 to the procedure code file, the 2010 MPFSDB, or appropriate on-line files to reflect an effective date of October 1, 2010. This change will also be updated on the January 2011 MPFSDB.
The payment indicators for Q2035, Q2036, Q2037, Q2038 and Q2039 are listed below:
Procedure Status: X WRVU: 0.00 Transitional Non-Facility PE RVU: 0.00 Fully Implemented Non-Facility PE RVU: 0.00
Transitional Facility PE RVU: 0.00 Fully Implemented Facility PE RVU: 0.00 Malpractice RVU: 0.00 PC/TC: Site of Service: Global Surgery: XXX Multiple Procedure Indicator: Bilateral Surgery Indicator: Assistant at Surgery Indicator: Co-Surgery Indicator: Team Surgery Indicator: Physician Supervision Diagnostic Indicator:
Manufacturer Trade Name (vaccine abbreviation)1 How Supplied MercuryContent (µg Hg/0.5mL) Age Group Vaccine Product Billing Code2 CPT Medicare3
AstraZeneca FluMist4 (LAIV4) 0.2 mL (single-use nasal spray) 0 2 through 49 years 90672 90672
GlaxoSmithKline Fluarix (IIV4) 0.5 mL (single-dose syringe) 0 3 years & older 90686 90686 ID Biomedical Corp. of Quebec, a subsidiary of GlaxoSmithKline FluLaval (IIV4) 0.5 mL (single-dose syringe) 0 6 months & older 90686 90686 5.0 mL (multi-dose vial) <25 6 months & older 90688 90688 Protein Sciences Corp. Flublok (RIV3) 0.5 mL (single-dose vial) 0 18 years & older 90673 90673 Sanofi Pasteur, Inc.
Fluzone (IIV4)
0.25 mL (single-dose syringe) 0 6 through 35 months 90685 90685
0.5 mL (single-dose syringe) 0 3 years & older 90686 90686
0.5 mL (single-dose vial) 0 3 years & older 90686 90686
5.0 mL (multi-dose vial) 25 6 through 35 months 90687 90687
5.0 mL (multi-dose vial) 25 3 years & older 90688 90688
Fluzone High-Dose (IIV3-HD) 0.5 mL (single-dose syringe) 0 65 years & older 90662 90662
Fluzone Intradermal (IIV4-ID) 0.1 mL (single-dose microinjection system) 0 18 through 64 years 90630 90630 Seqirus (formerly Novartis influenza vaccines and bioCSL) Afluria (IIV3) 0.5 mL (single-dose syringe) 0 9 years & older5,6 90656 90656 5.0 mL (multi-dose vial) 24.5 90658 Q2035
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