Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 2212 Date: May 5, 2011

Transcription

1 anual ystem Pub edicare laims Processing Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 2212 Date: ay 5, 2011 hange equest 7128 Transmittal 2154, dated ebruary 11, 2011, is being rescinded and replaced by Transmittal 2212 to remove the requirement in Business equirement ; arrier responsibility from Business equirements , , and ; and W responsibility from Business equirements and dditionally, no manual revisions will be made to chapter 18, sections , and ll other information remains the same. UBJET: Payment Update for nfluenza Virus Vaccine and Pneumococcal Vaccine odes. UY O NGE: This provides instructions for payment and W edits to be updated to include influenza virus vaccine P code and pneumococcal vaccine code, for claims with dates of service on or after October 1, 2010, processed on or after July 5, eferences to P code 90659, discontinued December 31, 2003, have been deleted from the manual. EETVE DTE: October 1, 2010 PLEENTTON DTE: July 5, 2011 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NGE N NUL NTUTON: (N/ if manual is not updated) =EVED, N=NEW, D=DELETED /N/D PTE / ETON / UBETON / TTLE 18/10.2.1/ealthcare ommon Procedure oding ystem(p) and Diagnosis odes. UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically

2 authorized by the contracting officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the contracting officer, in writing or by , and request formal directions regarding continued performance requirements. V. TTENT: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

3 ttachment Business equirements Pub Transmittal: 2212 Date: ay 5, 2011 hange equest: 7128 Transmittal 2154, dated ebruary 11, 2011, is being rescinded and replaced by Transmittal 2212 to remove the requirement in Business equirement ; arrier responsibility from Business equirements , , and ; and W responsibility from Business equirements and dditionally, no manual revisions will be made to chapter 18, sections , and ll other information remains the same. UBJET: Payment Update for nfluenza Virus Vaccine and Pneumococcal Vaccine odes Effective Date: October 1, 2010 mplementation Date: July 5, GENEL NOTON. Background: This provides instructions for the payment of influenza virus vaccine P code and pneumococcal vaccine (PPV) P code, for claims with dates of service on or after October 1, 2010, processed on or after July 5, B. Policy: Effective for claims with dates of service on or after October 1, 2010, processed on or after July 5, 2011, influenza virus vaccine P code and PPV P code will be payable by edicare.. BUNE EQUEENT TBLE Number equirement esponsibility (place an in each applicable column) / D hared- ystem OT E B E aintainers ontractors shall pay for influenza virus vaccine P code and pneumococcal vaccine (PPV) P code to hospitals (12 and 13), Ns (22 and 23), (34), hospital-based Ds (72), and s (85) based on reasonable cost ontractors shall pay for influenza virus vaccine P code and PPV P code to ospitals (12, 13), and s (85), based on 95% of the verage Wholesale Price (WP) ontractors shall pay for influenza virus vaccine P code and PPV P code to Os (75), and independent Ds (72), based on the lower of the actual charge or 95% of the WP. E V W

4 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OT E B E aintainers ontractors shall add influenza virus vaccine code to the existing influenza virus vaccine edits ontractors shall add PPV code to the existing pneumococcal vaccine edits This requirement deleted by ontractors shall not search their files to either retract payment for claims already paid or retroactively pay claims. owever, contractors shall adjust claims brought to their attention. E V W. POVDE EDUTON TBLE Numbe r equirement provider education article related to this instruction will be available at shortly after the is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in your next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. esponsibility (place an in each applicable column) / D hared- ystem OT E B E aintainers E V W

5 V. UPPOTNG NOTON ection : ecommendations and supporting information associated with listed requirements: hould" denotes a recommendation. -ef equirement Number ecommendations or other supporting information: N/ ection B: ll other recommendations and supporting information: N/ V. ONTT Pre-mplementation ontact(s): William uiz (410) Post-mplementation ontact(s): ontact your ontracting Officer s Technical epresentative (OT) or ontractor anager, as applicable. V. UNDNG ection : or iscal ntermediaries (s), arriers, and egional ome ealth ntermediaries (s): No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. ection B: edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the contracting officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the contracting officer, in writing or by , and request formal directions regarding continued performance requirements.

6 ealthcare ommon Procedure oding ystem (P) and Diagnosis odes (ev.2212, ssued: , Effective: , mplementation: ) Vaccines and their administration are reported using separate codes. The following codes are for reporting the vaccines only. P Definition nfluenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use; nfluenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use; nfluenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use; nfluenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use; nfluenza virus vaccine, live, for intranasal use; nfluenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use Pneumococcal conjugate vaccine, 13 valent, for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use; epatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use; epatitis B vaccine, adolescent (2 dose schedule), for intramuscular use; epatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use; epatitis B vaccine, adult dosage, for intramuscular use; and epatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use. The following codes are for reporting administration of the vaccines only. The administration of the vaccines is billed using: P G0008 Definition dministration of influenza virus vaccine;

7 G0009 dministration of pneumococcal vaccine; and *G0010 dministration of hepatitis B vaccine. *90471 mmunization administration. (or OPP hospitals billing for the hepatitis B vaccine administration) *90472 Each additional vaccine. (or OPP hospitals billing for the hepatitis B vaccine administration) * NOTE: or claims with dates of service prior to January 1, 2006, OPP and non-opp hospitals report G0010 for hepatitis B vaccine administration. or claims with dates of service January 1, 2006 and later, OPP hospitals report or for hepatitis B vaccine administration as appropriate in place of G0010. One of the following diagnosis codes must be reported as appropriate. f the sole purpose for the visit is to receive a vaccine or if a vaccine is the only service billed on a claim the applicable following diagnosis code may be used. Diagnosis ode Description V03.82 Pneumococcus V04.81** nfluenza V06.6*** Pneumococcus and nfluenza V05.3 epatitis B **Effective for influenza virus claims with dates of service October 1, 2003 and later. ***Effective October 1, 2006, providers may report diagnosis code V06.6 on claims for pneumococcus and/or influenza virus vaccines when the purpose of the visit was to receive both vaccines. f a diagnosis code for pneumococcus, hepatitis B, or influenza virus vaccination is not reported on a claim, contractors may not enter the diagnosis on the claim. ontractors must follow current resolution processes for claims with missing diagnosis codes. f the diagnosis code and the narrative description are correct, but the P code is incorrect, the carrier or intermediary may correct the P code and pay the claim. or example, if the reported diagnosis code is V04.81 and the narrative description (if annotated on the claim) says "flu shot" but the P code is incorrect, contractors may change the P code and pay for the flu vaccine. Effective October 1, 2006, carriers/b s should follow the instructions in Pub , hapter 1, ection (arrier Data Element equirements) for claims submitted without a P code. laims for hepatitis B vaccinations must report the.d. Number of the referring physician. n addition, if a doctor of medicine or osteopathy does not order the influenza virus vaccine, the intermediary claims require:

8 UPN code L000 to be reported on claims submitted prior to ay 23, 2008, when edicare began accepting NPs, only The provider s own NP to be reported in the NP field for the attending physician on claims submitted on or after ay 23, 2008, when NP requirements were implemented.