Procedure code and Description
Q2034: Influenza virus vaccine, split virus, for intramuscular use (Agriflu)
Q2035: Influenza virus vaccine, split virus, when administered to individuals 3 years of age & older, for intramuscular use (AFLURIA)
Q2036: Influenza virus vaccine, split virus, when administered to individuals 3 years of age & older, for intramuscular use (FLULAVAL)
Q2037: Influenza virus vaccine, split virus, for use in individuals 3 years of age & older, for intramuscular use (Fluvirin)
Q2038: Influenza virus vaccine, split virus, for use in individuals 3 years of age & older, for intramuscular use (Fluzone)
Q2039: Influenza virus vaccine, split virus, when administered to individuals 3 years of age & older, for intramuscular use
Vaccination:
An injection of a killed microbe in order to stimulate the immune system against the microbe, thereby preventing disease. Vaccinations, or immunizations, work by stimulating the immune system, the natural diseasefighting system of the body. The healthy immune system is able to recognize invading bacteria and viruses and produce substances (antibodies) to destroy or disable them. Immunizations prepare the immune system to ward off a disease. To immunize against viral diseases, the virus used in the vaccine has been weakened or killed. To only immunize against bacterial diseases, it is generally possible to use a small portion of the dead bacteria to stimulate the formation of antibodies against the whole bacteria. In addition to the initial immunization process, it has been found that the Effectiveness of immunizations can be improved by periodic repeat injections or “boosters.”
Clients age 19 and older
This section applies to clients age 19 and older. Refer to the Professional Administered Drugs Fee Schedule for a listing of covered vaccines for clients age 19 and older. Codes with a fee are paid according to the Professional Administered Drugs Fee Schedule.
Note: DOH supplies free vaccines for children 0-18 years only. For clients 18 years of age and younger, see the agency’s Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) Program Billing Guide.
• Bill the agency for the cost of the vaccine by reporting the procedure code for the vaccine given.
• Bill for the administration of the vaccine using CPT codes 90471 (one vaccine) and90472 (each additional vaccine). Reimbursement is limited to one unit of 90471 and one unit of 90472 (maximum of two vaccines).
• Bill for administration of nasal vaccine using CPT code 90473 (one vaccine) and 90474 (each additional vaccine). Reimbursement is limited to one unit of 90473 and one unit of 90474 (maximum of two vaccines).
• Providers are reimbursed for the vaccine using the agency’s maximum allowable fee schedule.
• Providers must bill 90471 and 90472 on the same claim as the procedure code for the vaccine.
If an immunization is the only service provided, bill only for the administration of the vaccine and the vaccine itself (if appropriate). Do not bill an E/M code unless a significant and separately identifiable condition exists and is reflected by the diagnosis. In this case, bill the E/M code with modifier 25. If the E/M code is billed without modifier 25 on the same date of service as a vaccine administration, the agency will deny the E/M code. Exception: The E/M code 99211 cannot be billed with a vaccine or the vaccine administration code.
Note: Meningococcal vaccines (CPT codes 90733 and 90734) require EPA. See EPA #870000421.
For Medicare beneficiaries, the seasonal influenza vaccine is usually administered once a year during the fall or winter months. Additional influenza vaccines (ie, the number of doses of a vaccine or the type of influenza vaccine) are covered by Medicare when medically necessary. Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is NOT a Part D covered drug.
FREQUENTLY ASKED QUESTIONS
Does the Medicare Part B deductible, coinsurance, or copayment apply for Part B-covered immunizations?
When physicians or suppliers agree to accept assignment, the Part B deductible, coinsurance, or copayment do not apply to the seasonal influenza virus, pneumococcal, and Hepatitis B vaccines or their administration.
If a beneficiary gets a seasonal influenza virus vaccine twice in a 12-month period, will Medicare still pay for it?
Yes, Medicare pays for one seasonal influenza virus vaccination per influenza season; however, a beneficiary could get the seasonal influenza virus vaccine twice in a calendar year for two different influenza seasons, and Medicare would pay the provider for each. For example, a beneficiary who received a seasonal influenza virus vaccination in January 2018 for the 2017–2018 influenza season could receive another seasonal influenza virus vaccination in November 2018 for the 2018–2019 influenza season, and Medicare would pay for both vaccinations.
Should providers administer the pneumococcal vaccination if a beneficiary is uncertain of his or her vaccination history?
Yes, if a beneficiary is uncertain about his or her vaccination history, and the provider cannot obtain verification from the beneficiary’s medical records, provide the vaccine. Medicare beneficiaries are eligible for the initial pneumococcal vaccine and a different pneumococcal vaccine one year after the first vaccine (at least 11 months have passed following the month when the last pneumococcal vaccine was administered).
Beneficiaries may be liable for the costs of the revaccination if they exceed the benefit maximum or if the timing of these services is sooner than the required 11 full months following the month of the last pneumococcal vaccine. We encourage providers to closely track vaccination history.
Does Medicare cover the hepatitis B vaccine for all Medicare beneficiaries?
No, Medicare covers the hepatitis B vaccine for certain beneficiaries at intermediate to high risk for the hepatitis B virus (HBV). These individuals include health care professionals who have frequent contact with blood or blood-derived body fluids during routine work, individuals with End-Stage Renal Disease (ESRD), individuals living with an HBV carrier, and individuals diagnosed with diabetes mellitus. Other situations could qualify a beneficiary as being at intermediate or high risk of contracting HBV. Medicare beneficiaries not eligible for this benefit are those currently positive for hepatitis B antibodies.
