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Billing Individual Influenza and Pneumococcal Pneumonia Vaccines

Beneficiaries must be eligible for Medicare Part B to receive Medicare reimbursement for vaccines. When the same type of vaccine is administered to fewer than five Medicare beneficiaries on the same day, you must submit the claim(s) individually. Roster Billing for Mass Influenza and Pneumococcal Pneumonia Vaccines is only available when the same type of vaccination is given to five or more people on the same date of service. Individual claims may be submitted using the ANSI ASC X12N 837 format, or by entering the claim directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry.

  • Home Health providers using FISS DDE to submit individual claims will access 'Home Health' Option 26 from the Claims Entry menu. The influenza virus vaccine and pneumococcal pneumonia vaccination (PPV) are billed on a 341 type of bill (home health outpatient Part B benefit).
  • Hospice providers may submit claims for vaccines with dates of service on or after October 1, 2016. Vaccines may be covered when furnished by a hospice to those beneficiaries who request them, including those who have elected the hospice benefit.

    When using FISS DDE, hospice providers would access 'Hospice' Option 28 from the Claims Entry menu. Because vaccinations are not part of the Medicare hospice benefit, hospice claims (type of bill 81X or 82X) for vaccine services must be billed on a separate claim and must only include charges for the vaccine and their administration.

When using FISS DDE, in addition to the usual information that is required on Medicare claims, include the following vaccination coding requirements:

Claim Information

Influenza Virus Vaccine / PPV

TOB (type of bill)

341 – Home health outpatient (Part B)
81X – Hospice (nonhospital based)
82X – Hospice (hospital based)

STMT DATES
FROM/TO
(dates of service)

Enter the single date of service in which the vaccine was provided in the FROM and TO date field.

TYPE (Admit Type)

Enter the 1-digit code indicating the type of admission. If you are unsure which code to enter, use code 9 (information not available).
1 – Emergency
2 – Urgent
3 – Elective
4 – Newborn
5 – Trauma
9 – Information not available

STAT (patient status)

01 – discharge status

COND CODES (Condition Code)

A6 – PPV/Medicare Pneumococcal Pneumonia/Influenza 100% Payment

REV (Revenue Code)

0636 for the vaccine
0771 for the administration

HCPC
(Healthcare Common Procedure Code))

For a complete list of HCPCS codes for the Influenza Virus Vaccine and Pneumococcal Pneumonia Vaccine, refer to the Medicare Claims Processing Manual (Pub. 100-04), Chapter 18, §10.2.1.External PDF

NOTE: HCPCS code 90471 and 90472 should not be used to bill the administration of the influenza virus vaccine or the pneumococcal pneumonia vaccine. These codes are only used by hospitals billing for the administration of the hepatitis B vaccine.

RI (Release of Information)

Y – A signed statement is on file permitting release of data.
N – No release is on file.

DIAG CODES 01 (Principal Diagnoses code)
  • For services on or after October 1, 2015,ICD-10-CM diagnosis code Z23 may be used.
  • For services prior to October 1, 2015:
    • V04.81 (influenza virus vaccine)
    • V03.82 (PPV)
    • Note: Use V06.6 in place of V04.81 and V03.82 when giving both PPV and influenza vaccines during the same visit

ATT PHYS NPI, L, F (Attending physician National Provider Identifier, last name and first name)

Enter the physician's NPI if available, along with the last name in the 'L' field, and the first name in the "F' field. When the physician's NPI is not available, the home health or hospice agency should submit their own NPI in this field. In addition:

  • Enter "Roster" in the 'LN' (last name) field; and
  • Enter "Bill" in the 'FN' (first name) field.

Additional Resources

Updated: 12.09.20

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