Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA08.007q


Attachment:C

Policy #:MA08.007q

Description:Vaccination and inoculation coverage.

Title:Medicare Part B vs. Part D Crossover Drugs


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.


VACCINE COVERAGE

Vaccinations, or inoculations, are excluded under the Medicare medical benefit (Part B) unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as the following:
  • Anti-rabies treatment
  • Tetanus antitoxin or booster vaccine
  • Botulin antitoxin
  • Antivenin sera
  • Immune globulin

In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against diseases (e.g., smallpox, polio, diphtheria) is not covered under the medical benefit (Part B). However, Pneumococcal, Hepatitis B, and Influenza virus vaccines are exceptions to this rule.

The following vaccines are always covered under Part B and are never covered under the Medicare pharmacy benefit (Part D):
  • The Pneumococcal vaccine is covered under Part B regardless of whether the vaccine is administered without a physician’s order and without physician supervision.
    • A second pneumococcal vaccine may be administered a year after the first vaccine was administered.
Code
90670
90732
  • The Influenza vaccine is covered under Part B regardless of whether the vaccine is ordered by a doctor of medicine or osteopathy.
Code
90630
90653
90654
90655
90656
90657
90658
90660
90661
90662
90664 *
90666 *
90667 *
90668 *
90672
90673
90674
90682
90685
90686
90687
90688
90689
90694
90756
Q2034
Q2035
Q2036
Q2037
Q2038
Q2039

The following vaccines are only covered under the Part B when reported with the appropriate diagnosis codes listed in the attachments of this policy. In all other instances, the vaccines will not be covered under Part B and will only be covered under Part D.
  • The Hepatitis B vaccine is covered under Part B when given to an individual who is at high or intermediate risk of contracting Hepatitis B. (See Attachment D for the definition of high or intermediate risk and all the applicable diagnoses that meet this definition.)
Code
90739
90740
90743
90744
90746
90747
  • The tetanus vaccine is covered under Part B when given to treat an acute injury sustained by an individual who is incompletely immunized.
  • To report the tetanus vaccine (90714) administration for the treatment of an injury or direct exposure to a disease or condition, append modifier AT (acute treatment) to the code for the vaccine to be covered under Part B, medical benefit. Claims submitted without modifier AT will be denied under Part B and will only be covered under the Medicare pharmacy benefit (Part D) for Medicare Advantage members who purchased this coverage.
Code
90714

  • The rabies vaccine is covered under Part B when given to an individual who is at high risk for rabies following an encounter with an animal. All other indications will be denied under Part B and will only be covered under the Medicare pharmacy benefit (Part D) for Medicare Advantage members who purchased this coverage.
Code
90675
90676 *


The following vaccines are never covered under Part B and are only covered under Part D:

Code
90476
90477
90581
90585
90586
90587 *
90619 *
90620
90621
90625
90632
90633
90634
90636
90644
90647
90648
90649
90650
90651
90680
90681
90690
90691
90696
90697
90698
90700
90702
90707
90710
90713
90715
90716
90717
90723
90733
90734
90736
90738
90748
90749
90750
J3530

*At the time of this policy being published, there is no US Food and Drug Administration (FDA) approval for these vaccines; therefore, these vaccines are considered experimental/investigational, and are not covered under any benefit.




Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A

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