Medicare Compliance & Reimbursement

Tip: Review the basics before submitting claims.

For many Medicare providers, the fall flu clinic has become a popular means of vaccinating beneficiaries en masse. Moreover, the option of roster billing makes the claims process much more efficient for providers who do large group influenza immunizations annually.

Heads up: Healthcare practitioners cannot just decide one day to jump on the flu clinic bandwagon and submit roster billing to Medicare. There is a process for becoming a mass immunizer that includes state licensure, Medicare provider enrollment, specific forms, and coordination with the A/B Medicare Administrative Contractor (MAC) in your jurisdiction.

Read on for a 10-point primer on roster billing.

1. Figure Out If Your Organization Can Do Mass Immunizations

Mass immunizers come in all shapes and sizes — from typical physician practices to non-traditional suppliers like grocery store pharmacies, acknowledges Part B MAC Palmetto GBA in online guidance. According to the Centers for Medicare & Medicaid Services (CMS), mass immunizers must do the following:

• Be licensed in the state where they’re administering the flu or pneumococcal shots;
• Enroll as a Medicare provider;
• Accept Medicare payment as is without deductibles or copays; and
• Submit claims using roster billing.

2. Check Medicare Provider Enrollment Requirements

To submit these types of claims, you must enroll in the Medicare program — even if you plan on enrolling only as a mass immunizer because you want to do a flu shot clinic. So, if you choose to follow through on the Medicare provider enrollment, you must choose the specialty type as 73 (Mass immunization roster biller) for the application to be accepted. Individual applicants like physicians or nonphysician practitioners (NPPs) must submit a CMS-855I form while group practices, clinics, and other suppliers apply via a CMS-855B.

3. Understand Flu Season Parameters

According to CMS, payments for influenza vaccinations run from Aug. 1 to July 31 each year.

Influenza vaccinations are given per flu season and not by year, so Medicare beneficiaries can reasonably receive more than one booster a year as long as the shot is medically necessary and the documentation is in the notes, indicated NGS Medicare’s Michelle Coleman CPC, in a webinar. “You can receive more than one flu vaccination per year,” she explained. “The way we pay it is per season.”

For example, you could administer a flu shot in January 2021 — which falls under Medicare’s 2020/2021 reimbursement effective dates — and your patient could come in again in October 2021 for another vaccination because that is considered part of the 2021/2022 flu season.

Caveat: Depending on your billing cycle, you may want to double check the effective payment date of the CPT^® codes you are submitting. CMS lists four codes for the 2020/2021 flu season that aren’t effective until after Aug. 1.

See the list at www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.

4. Get the Scoop on These Billing Differentials

There are three different roster billing categories: institutional claims, professional claims, and centralized billing. Here’s a brief breakdown:

• Institutional claims: “Roster billing institutional vaccine claims requires administering a vaccine to at least five patients on the same date, unless the institution is an inpatient hospital,” CMS says. There are two required forms that these mass immunizers must use to submit claims, the CMS-1450 form and a MAC-specific roster form.
• Professional claims: Providers should submit professional claims via a modified CMS-1500 and a roster bill form from the MAC in their jurisdiction. “The roster billing form allows you to report five patients per page and can be submitted two-sided to allow 10 patients per page. It is acceptable to submit up to 10 pages per 1500 claim form,” advises Part B MAC Novitas Solutions in online guidance.
• Centralized billing: Mass immunizers administering flu shots in three or more states can utilize centralized billing. This option allows providers to send all their claims to one designated MAC. If you “operate in at least three payment localities where three different MACs process claims,” you may be eligible for this streamlined billing process — as long as you are licensed in the states where the shots are given, notes agency guidance. The process takes 8 to 12 weeks and must be completed using the appropriate Medicare provider enrollment form “by June 1 of the year you plan to begin centralized billing,” CMS says.

Tip: “You cannot mix vaccines on the same roster bill. You must use separate claims and roster bills for influenza and pneumococcal or the claims will be rejected,” emphasizes Colman.

5. Use the Correct CPT^® Code and HCPCS Code

“The codes vary based on the drug manufacturer, so you’d bill according to which code is applicable to your office,” advised Coleman.

Remember, you’ll report two codes for each vaccination claim: one administrative code and one vaccine code. “To administer the influenza vaccine you will use the HCPCS code G0008 (Administration of influenza virus vaccine) in addition to the CPT^® code, which is the actual vaccine itself,” Coleman reminded. You’ll report HCPCS code G0009 (Administration of pneumococcal vaccine) as the administration code for pneumococcal immunizations.

Remember: Age also factors into your code choice. Before you write up your claim, you may want to crosscheck the beneficiary’s age against the CPT^® code used.

6. Don’t Forget ICD-10-CM

Mass immunizers submitting both flu and pneumonia vaccine claims must always use Z23 (Encounter for immunization) as their diagnosis code. “Claims submitted with an invalid or incomplete diagnosis code will be rejected and must be resubmitted with corrected information as new claims,” Palmetto GBA cautions.

7. Ensure Documentation Is in Order

Even though roster billing does trim down the claims process, that doesn’t mean you can cut corners on your documentation.

Why? Documentation backs up the services performed and explains the medical necessity. Illegible notes or lack of documentation leads to denials — and potential false claims issues down the road.

Signature rules: “The patient or authorized representative must sign the roster unless the signature is on file,” according to Palmetto GBA’s Part B guidance. “The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider, when the provider accepts assignment on the claim.”

You can opt to have your beneficiaries sign the Centers for Disease Control and Prevention (CDC) form HEA 3314 instead of the roster, too. Additionally, “if the beneficiary’s actual signature cannot be obtained, the phrase ‘signature on file’ can be used if you have a signed authorization on file from the beneficiary to bill Medicare for services,” Novitas Solutions says.

8. Download Your MAC’s Roster Billing Form

Your MAC will have a jurisdiction-specific roster billing form that it would like you to use; however, some of the MACs allow providers to make their own forms.

Part B MAC CGS Medicare recommends the forms include the following items: provider’s name and NPI; date of service; CMS control number; and patients’ names, Medicare Beneficiary Identifiers (MBIs), personal information, and signatures.

Check with your MAC before submission to see your roster-form options.

9. Realize Roster Bill Payments Take Longer to Clear

“Roster bills are considered paper claims and are not paid as quickly as claims submitted electronically,” acknowledges Palmetto GBA. That means the mass immunization claims follow the same reimbursement rules as any other Medicare paper claims. The payment floor is 28 days — and providers will not be reimbursed before the 29th day after their claims were received by CMS.

10. Expect Denials to Come Back Through Normal Routes

If your roster billing claim is returned, it will go through traditional means, Novitas Solutions suggests. “If a claim is returned for incomplete or invalid information, you will receive notification on your normal voucher or reconciliation file with the appropriate returned information. It is your responsibility to verify that all information is complete before resubmitting the claim,” warns the Part B MAC.