Immunizations – Medicare Advantage Billing Guidelines

Medicare Covered Part B Immunization

Medicare covers certain vaccinations under Part B as preventive services, these vaccines are below:

• Pneumococcal vaccine
• Influenza virus vaccine
• Hepatitis B vaccine*
• COVID-19 vaccine

*Available to members who are at high or intermediate risk of contracting hepatitis B, e.g., exposed to hepatitis B.

Billing Guidelines

Refer to Section 10 [PDF] of Medicare Claims Processing Manual, Chapter 18 for the pneumococcal, influenza and hepatitis B vaccine codes and administrations, and their coverage and billing guidelines.

The COVID-19 vaccines and its administration are posted at: https://www.cms.gov/monoclonal

Reminder: Providers should report the corresponding vaccine administration codes below when billing for the preventive service vaccines to ensure appropriate benefit is applied.

There are other vaccines that are covered under Part B when they are directly related to treatment of an injury or direct exposure to a disease or condition.

Below are other Part B vaccines that are covered when it meets medical necessity criteria.

Administration for non-preventive Vaccines

Covered ICD-10 Codes for Tetanus, Diphtheria and Pertussis vaccines (CPT codes 90702, 90714, and 90715) [PDF]

Diagnosis codes must be coded to the highest level of specificity. Click Covered ICD-10 Codes for list.

Covered ICD-10 Codes for Diphtheria, antitoxin (CPT code 90296)

Covered ICD-10 Codes for Hepatitis A vaccine (CPT codes 90632, 90633 and 90634)

Covered ICD-10 Codes for Rabies Prophylaxis (CPT codes 90675 and 90676)

Medicare Covered (Part D) Vaccinations

Part D plans covers all commercially available vaccines when reasonable and necessary to prevent illness.

Refer to additional covered Part D adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) here.

The following procedure codes are always non-covered by Medicare Part B but may be covered by Medicare Part D plans (refer to the formulary):

If the Medicare Advantage member does not have Part D coverage, plan pays for respiratory syncytial virus (RSV) vaccine administration but not the vaccine under Part B.

Effective for dates of service on and after October 6, 2023, providers can submit RSV vaccine administration under Part B with below codes:

Billing Guidelines for Non-covered Immunization

Append GY modifier when billing non-covered Part B vaccines and administration.

An example:

References:

CMS Local Coverage Determinations (LCDs) and Articles

Revision History