Billing and Coding: Medicare Preventive Coverage for Certain Vaccines

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

Medicare provides preventive coverage only for certain vaccines. These include:

• Novel Coronavirus (COVID-19): guidance can be found here - https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/vaccine-pricing 
• Influenza: once per flu season (codes 90630, 90637, 90638, 90653-90657, 90660-90662, 90672-90674, 90682, 90685-90689, 90694, 90756, Q2034-Q2039)
  • Claim should contain HCPCS G0008 and ICD-10 Z23
  • Effective for dates of service 8/01/2017-12/31/2017 claims for Flucelvax Quadrivalent influenza vaccine should be billed utilizing HCPCS Q2039 (Influenza virus vaccine, not otherwise specified).
  • Note: Claims billed for dates of service prior to 12/31/2017, if submitted on or after 01/01/2018, must bill HCPCS Q2039 for the claim to process correctly.
  • Note: CPT^® code 90694 is effective for claims processed with dates of service on or after 7/1/2020.

• Pneumococcal: An initial pneumococcal vaccine to Medicare beneficiaries who have never received the vaccine under Medicare Part B; and a different, second pneumococcal vaccine 1 year after the first vaccine was administered (codes 90670, 90671, 90677 and 90732)
• Claim should contain HCPCS G0009 and ICD-10 Z23
• Pneumococcal and Seasonal Influenza Virus Vaccines received during the same visit (use seasonal influenza virus and pneumococcal vaccine codes)
• Claim should contain HCPCS G0008 AND G0009 AND ICD-10 Z23

• Hepatitis B: for persons at intermediate-to high-risk only (codes 90739-90740, 90743-90744, 90746-90747, 90759). People who are considered high or medium risk for hepatitis B are:
1. Those with End-Stage Renal Disease (ESRD) also known as kidney failure
2. Hemophiliacs
3. Clients and staff at institutions for the developmentally disabled
4. Those who live in the same household as a hepatitis B carrier
5. Homosexual men
6. Illicit drug users
7. Health care professionals who have frequent contact with blood or other body fluids during routine work

-Claim should contain HCPCS G0010 and ICD-10 Z23

• Other immunizations are covered under Medicare only if they are directly related to the treatment of an injury or direct exposure:
• Rabies (90675-90676)
• Claim should contain Z20.3
• Tetanus (90702, 90714, and 90715)

Claims should be coded with the diagnosis appropriate to the injury- see the ICD-10-CM Codes that Support Medical Necessity section of this article.