Corporate

November 12, 2019

Influenza Vaccine Invoice

The Centers for Medicare & Medicaid Services (CMS) has established pricing for most influenza vaccinesExternal Website.  Those without pricing information are priced based on the actual invoice. This includes:

  • CPT code 90630 - Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use
  • CPT code 90655 - Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use
  • CPT code 90656 - Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use
  • CPT code 90657 - Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use
  • CPT code 90661 -  Influenza virus vaccine, derived from cell cultures; subunit
  • CPT code 90673 -  Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use
  • HCPCS code Q2034 - Influenza virus vaccine, split virus, for intramuscular use (agriflu)
  • HCPCS code Q2035 - Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (afluria)
  • HCPCS code Q2036 - Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (flulaval)
  • HCPCS code Q2037 - Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluvirin)
  • HCPCS code Q2038 - Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluzone)
  • HCPCS code Q2039 - Influenza virus vaccine, not otherwise specified (used only when there is no code for the vaccine administered)

Because of this, claims submitted for the above listed vaccines must include either invoice information or a copy of the actual invoice for pricing purposes.  NOTE:  Please be sure the invoice information is for the actual flu vaccine submitted on the claim.

Electronic Claims
Please report this information in the electronic Documentation Field (Loop 2300, NTE Segment (header level) or Loop 2400, NTE Segment (line level)).

  • The name of the drug and the exact dosage administered must appear in the Documentation Field.
    • If the charge matches the actual invoice cost, note "Actual Invoice Cost" in the Documentation Field.
    • If you are submitting a charge greater than the actual invoice cost, please include the following information in the Documentation Field, using these abbreviations:
      • Des = Description/Name of vaccine (e.g., Des=Afluria)
      • QS = Quantity shipped (e.g., QS=100mg)
      • TA = Total amount charged for quantity shipped (e.g., TA=$57.40)
      • UP = Unit Price (e.g., UP = $50.57 per mg) (Optional)
      • DG = Dosage given (e.g., DG= .25 mL)
  • In lieu of submitting the invoice information above, you may use the Paperwork (PWK) process and send a copy of the invoice via fax or mail.

Paper Claims
If you are approved to submit paper claims, submit this information in Item 19 of the CMS-1500 claim form and provide a copy of the actual invoice.

NOTE: Claims submitted with the CPT/HCPCS codes above that are received without the invoice information or the actual invoice may be denied or delayed.

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