CPT CODE and description
90686 - Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use -
90715 - Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular us
Tdap Tetanus -Diphtheria -Pertussis Boostrix SKB Pedi: 1 dose at 11-12 years; Catch-up vaccination < 19 yrs; during each pregnancy 0.5 mL IM 90715 115 Free Adacel PMC Adult: 1 dose for unvaccinated adults >19 years ; vaccinate pregnant5 women during each pregnancy; Varicella Chickenpox Varivax MSD Pedi & Adult: 1 st dose at 12-15 months; catch-up vaccination
children and adults 19- 26 years 0.5 mL SC 90716 21 Free
DT & Tdap/Td Administration of influenza virus vaccine Varicella virus vaccine (VAR), live, for subcutaneous use (Varivax) Influenza Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use Tetanus, diphtheria toxoids and acellular pertussis (Tdap), when administered to individuals 7 years or older, for intramuscular use
Background
This recurring update notification provides the payment allowances for the following seasonal infl uenza virus vaccines, when payment is based on 95 percent of the Average Wholesale Price (AWP).
The Medicare Part B payment allowances for the following Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes below apply for the effective dates of August 1, 2015 July 31, 2016:
• CPT 90655 Payment allowance is pending;
• CPT 90656 Payment allowance is pending;
• CPT 90657 Payment allowance is pending;
• CPT 90661 Payment allowance is pending;
• CPT 90685 Payment allowance is pending;
• CPT 90686 Payment allowance is pending;
• CPT 90687 Payment allowance is pending;
• CPT 90688 Payment allowance is pending;
• HCPCS Q2035 Payment allowance is pending;
• HCPCS Q2036 Payment allowance is pending;
• HCPCS Q2037 Payment allowance is pending; and
• HCPCS Q2038 Payment allowance is pending.
Submit claims for shingles or tetanus vaccinations to Medicare Part D
Providers who have administered a shingles (90736; regardless of any diagnosis) or tetanus vaccine (90714, 90715, 90718 & 90723; regardless of any diagnosis) to our individual and group-sponsored Medicare Advantage plan members with pharmacy benefits should bill the Medicare Part D Benefit. Providers will encounter a denial if these claims are billed to the Medical benefit because the claim is covered under Medicare Part D only. This applies to the vaccine and the administration charges. Please note you can refer your patients to their local pharmacy for administration as well.
For Medicare Part B benefit of tetanus vaccine (90703; diagnosis range 800.00 to 897.99), this may be submitted as a medical claim for processing.
A given service or procedure billed to the Medicare program may not be linked to a National Coverage Determination (NCD) or Local Coverage Determination (LCD). Assuming all other requirements of the program are met and absent specific coverage criteria outlined in a LCD or NCD, all procedures or services must meet the medically reasonable and necessary threshold for coverage as demonstrated by the performing provider or attending physician in the official medical record. The Noncovered Services LCD compiles services or procedures that have been addressed by the Medical Policy department as to the medically reasonable and necessary threshold for coverage. Certain services or procedures will not have specific level I or level II HCPCS coding. Such services or procedures would be coded as the appropriate unclassified code. Occasionally services or procedures will be identified by a specific level I (Category I or Category III CPT code) or level II HCPCS code. It is the expectation that physicians and allied providers code to specificity. Payment of a claim is not a coverage statement especially if payable codes were used to bypass the medical review of more specific Level I/Category I unlisted codes or Level I/Category III codes or level II HCPCS codes.
In determining if a service or procedure reaches the threshold for coverage, this contractor addresses the quality of the evidence per the program integrity manual in making its recommendation to non-cover a service, pending new information in the public domain. This recommendation is taken through the LCD development process (draft recommendation of noncoverage, 45-day comment period, CAC advisory meeting, open public meeting, finalization, and 45-day notice period). Any interested stakeholder can request a reconsideration of an LCD after the notice period. In the case of the Noncovered Services LCD the stakeholder will receive a list of the articles and related information in the public domain that were addressed by the Medical Policy department in making the noncoverage decision. If the stakeholder has new information based on the evaluation of the list, a LCD reconsideration can be initiated. It is the responsibility of the interested stakeholder to request the evidentiary list from the contractor and to submit the additional articles, data, and related information in support of their request for coverage. The request must meet the LCD reconsideration requirements outlined on the web site.
It is not unusual that there will be a paucity of information for an emerging technology or service, and the Medial Policy department may noncover a service as noted in this LCD awaiting information in the public domain on safety and efficacy based on the quality of evidence. Also this contractor may be silent in terms of LCD in regard to a service or procedure (such a procedure or service is not listed in the Noncovered Services LCD or has been removed from the Noncovered Services LCD). A service or procedure not addressed in the Noncovered Services LCD is not a positive coverage statement. Claims for such services assuming all other requirements of the program are met would always need to meet the medically reasonable and necessary threshold for coverage in a prepayment or post payment audit of the official medical record.
90686 - Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use -
90715 - Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular us
Tdap Tetanus -Diphtheria -Pertussis Boostrix SKB Pedi: 1 dose at 11-12 years; Catch-up vaccination < 19 yrs; during each pregnancy 0.5 mL IM 90715 115 Free Adacel PMC Adult: 1 dose for unvaccinated adults >19 years ; vaccinate pregnant5 women during each pregnancy; Varicella Chickenpox Varivax MSD Pedi & Adult: 1 st dose at 12-15 months; catch-up vaccination
children and adults 19- 26 years 0.5 mL SC 90716 21 Free
DT & Tdap/Td Administration of influenza virus vaccine Varicella virus vaccine (VAR), live, for subcutaneous use (Varivax) Influenza Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use Tetanus, diphtheria toxoids and acellular pertussis (Tdap), when administered to individuals 7 years or older, for intramuscular use
Background
This recurring update notification provides the payment allowances for the following seasonal infl uenza virus vaccines, when payment is based on 95 percent of the Average Wholesale Price (AWP).
The Medicare Part B payment allowances for the following Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes below apply for the effective dates of August 1, 2015 July 31, 2016:
• CPT 90655 Payment allowance is pending;
• CPT 90656 Payment allowance is pending;
• CPT 90657 Payment allowance is pending;
• CPT 90661 Payment allowance is pending;
• CPT 90685 Payment allowance is pending;
• CPT 90686 Payment allowance is pending;
• CPT 90687 Payment allowance is pending;
• CPT 90688 Payment allowance is pending;
• HCPCS Q2035 Payment allowance is pending;
• HCPCS Q2036 Payment allowance is pending;
• HCPCS Q2037 Payment allowance is pending; and
• HCPCS Q2038 Payment allowance is pending.
Submit claims for shingles or tetanus vaccinations to Medicare Part D
Providers who have administered a shingles (90736; regardless of any diagnosis) or tetanus vaccine (90714, 90715, 90718 & 90723; regardless of any diagnosis) to our individual and group-sponsored Medicare Advantage plan members with pharmacy benefits should bill the Medicare Part D Benefit. Providers will encounter a denial if these claims are billed to the Medical benefit because the claim is covered under Medicare Part D only. This applies to the vaccine and the administration charges. Please note you can refer your patients to their local pharmacy for administration as well.
For Medicare Part B benefit of tetanus vaccine (90703; diagnosis range 800.00 to 897.99), this may be submitted as a medical claim for processing.
A given service or procedure billed to the Medicare program may not be linked to a National Coverage Determination (NCD) or Local Coverage Determination (LCD). Assuming all other requirements of the program are met and absent specific coverage criteria outlined in a LCD or NCD, all procedures or services must meet the medically reasonable and necessary threshold for coverage as demonstrated by the performing provider or attending physician in the official medical record. The Noncovered Services LCD compiles services or procedures that have been addressed by the Medical Policy department as to the medically reasonable and necessary threshold for coverage. Certain services or procedures will not have specific level I or level II HCPCS coding. Such services or procedures would be coded as the appropriate unclassified code. Occasionally services or procedures will be identified by a specific level I (Category I or Category III CPT code) or level II HCPCS code. It is the expectation that physicians and allied providers code to specificity. Payment of a claim is not a coverage statement especially if payable codes were used to bypass the medical review of more specific Level I/Category I unlisted codes or Level I/Category III codes or level II HCPCS codes.
In determining if a service or procedure reaches the threshold for coverage, this contractor addresses the quality of the evidence per the program integrity manual in making its recommendation to non-cover a service, pending new information in the public domain. This recommendation is taken through the LCD development process (draft recommendation of noncoverage, 45-day comment period, CAC advisory meeting, open public meeting, finalization, and 45-day notice period). Any interested stakeholder can request a reconsideration of an LCD after the notice period. In the case of the Noncovered Services LCD the stakeholder will receive a list of the articles and related information in the public domain that were addressed by the Medical Policy department in making the noncoverage decision. If the stakeholder has new information based on the evaluation of the list, a LCD reconsideration can be initiated. It is the responsibility of the interested stakeholder to request the evidentiary list from the contractor and to submit the additional articles, data, and related information in support of their request for coverage. The request must meet the LCD reconsideration requirements outlined on the web site.
It is not unusual that there will be a paucity of information for an emerging technology or service, and the Medial Policy department may noncover a service as noted in this LCD awaiting information in the public domain on safety and efficacy based on the quality of evidence. Also this contractor may be silent in terms of LCD in regard to a service or procedure (such a procedure or service is not listed in the Noncovered Services LCD or has been removed from the Noncovered Services LCD). A service or procedure not addressed in the Noncovered Services LCD is not a positive coverage statement. Claims for such services assuming all other requirements of the program are met would always need to meet the medically reasonable and necessary threshold for coverage in a prepayment or post payment audit of the official medical record.