In November, CMS finalized a change to how RHCs and FQHCs will bill for certain Part B Preventive vaccines as part of the 2025 Medicare Physician Fee Schedule Final Rules. These changes will not be effective until July 1, but will impact billing for influenza, pneumococcal, COVID-19, and Hepatitis B vaccines. These vaccines, currently reimbursed at 100% of reasonable cost through the Medicare cost report (with the exception of Hepatitis B), will now be billed at time of service with a cost report reconciliation to ensure clinics are paid according to Medicare statute.
Late last week, CMS published MLN Matters Article MM13923 providing further guidance on expected payment of these vaccines, along with instructions to the Medicare Administrative Contracts (MAC) as part of Change Request 13923, dated for release on January 16, 2025.
The MLN article text can be found here: MLN 13923 – Payment for Medicare Part B Preventive Vaccines & Their Administration for RHCs & FQHCs.
For ease of understanding, here is a summary of the changes included in CR13923:
- These Part B preventive vaccines, and their administration will be billed on the UB-04 claim form (Bill Type 71X or 77X).
- A visit / encounter or qualifying visit code is NOT required to be reported on the same claim as these Part B preventive vaccine in order to receive separate reimbursement.
- MACs will modify the roster billing process to also allow entry for 77X bill types. (The current Roster Bill process only allows entry for 71X bill types.)
- MACs will modify existing edits and reason codes to allow for Roster Billing services for Part B preventive vaccines and their administration.
- MAC will make separate payment at the lesser of 95% of the Average Wholesale Price (AWP), as displayed on the Medicare Average Sales Price(ASP) files, or the submitted charges for service lines reporting Part B preventive vaccine products when reported on bill types 71X or 77X.
- MAC will make separate payment at the lesser of the Medicare Physician Fee Schedule (MPFS) rates or the submitted charges for service lines reporting Part B preventive vaccine administration codes. This includes new in-home vaccine administration code M0201 for qualifying clinics.
- MAC will make separate payment for Part B preventive vaccine products and administration when reported on bill type 71X with or without the CG modifier present on the service line.
- Beneficiary coinsurance and deductible will be waived for Part B preventive vaccine products and administration. (Presumably, this also means that Part B preventive vaccine products and administration charges will not be rolled up into the CG modifier, or qualifying visit line (when present), in the same manner as other qualifying preventive health services.)
The full text of the Medicare Change Request can be viewed here: Medicare Change Request 13923.
Again, these changes will not take place until July 1st, 2025, but RHCs and FQHCs should reach out to their software vendors now in case any system updates or changes are needed. At present, we also do not have any further guidance regarding the vaccine reconciliation process that will be part of the Medicare Cost Report. Once those details are published, we will issue more information.
If you have questions about implementing these changes in your RHC or FQHC, or if you have questions about any other recent changes impacting your clinic, please reach out to Amanda Dennison at adennison@blueandco.com, or your trusted Blue Advisor.
