According to the Centers for Disease Control and Prevention (CDC), there have been 22,364 laboratory confirmed hospitalizations and 877 laboratory‐confirmed deaths in the United States attributed to Influenza A (H1N1) from August 30 to November 7, 2009.1 Additionally, the CDC states that the “total influenza hospitalization rates for laboratory‐confirmed flu continue to climb and remain higher than expected for this time of [the] year.”2 Thus, with the flu season underway, the current impact of H1N1 in the population, and the increased media attention on influenza, healthcare providers have and will continue to see an increase in requests for influenza vaccinations. Consequently, issues regarding Medicare reimbursement may arise. Therefore, it is imperative for providers to understand the Centers of Medicare and Medicaid Services (CMS) billing rules regarding influenza virus vaccinations in order to accurately bill and receive correct reimbursement.
Does Medicare Cover Influenza Virus Vaccines?
CMS provides coverage for influenza virus vaccines and its administration when in compliance with applicable State laws. However, vaccines for the H1N1 virus are not covered since the vaccines are provided to physicians at no cost. Therefore, CMS will only cover the administration of H1N1 but not the actual vaccine. Providers are thus not required to bill Medicare for the H1N1 vaccine. However, if a claim is submitted reporting the Healthcare Common Procedure Coding System (HCPCS) code G9142, H1N1 vaccine code, CMS contractors will accept the bill but deny the claim line