CR9357 provides that (effective for claims with dates of service on or after August 1, 2015, processed on or after April 4, 2016) Medicare will pay for vaccine Current Procedural Terminology (CPT) code 90630 (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use).
Your MAC will add influenza virus vaccine CPT code 90630 to existing influenza virus vaccine edits and accept it for claims with dates of service on or after August 1, 2015.
Effective for dates of service on and after August 1, 2015, MACs will:
• Pay for vaccine code 90630 on institutional claims as follows:
o Hospitals – Types of Bill (TOB) 12X and 13X, Skilled Nursing Facilities (SNFs) –TOB 22X and 23X, Home Health Agencies (HHAs) – TOB 34X, hospital-based Renal Dialysis Facilities (RDFs) – TOB 72X, and Critical Access Hospitals (CAHs) – TOB 85X, based on reasonable cost;
o Indian Health Service (IHS) Hospitals – TOB 12X, and 13X and IHS CAHs – TOB 85X, based on the lower of the actual charge or 95 percent of the Average Wholesale Price (AWP); and
o Comprehensive Outpatient Rehabilitation Facility (CORF) – TOB 75X, and independent RDFs – TOB 72X, based on the lower of actual charge or 95 percent of the AWP.
• Pay for code 90630 on professional claims using the CMS Seasonal Influenza Vaccines Pricing webpage at https://www.cms.gov/Medicare/Medicare-Fee-forService-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html
to determine the payment rate for influenza virus vaccine code 90630.
Note: In all of the above instances, annual Part B deductible and coinsurance do not apply.
In addition, until Medicare systems changes are implemented, MACs will hold institutional claims containing influenza virus vaccine CPT codes 90630 (with dates of service on or after August 1, 2015) that they receive before April 4, 2016. Once the system changes described in CR9357 are implemented, these institutional claims will be processedand paid.