Medicare Part D Billing

Excerpt from Medicare Part D Manual Regarding Vaccine Administration

(Rev. 2, Issued: 07-18-08; Effective/Implementation Date: 07-18-08)

Beginning on January 1, 2008, the Part D program will cover vaccine administration costs associated with Part D vaccines. CMS interprets this statutory requirement to mean that the Part D vaccine administration costs are a component of the negotiated price for a Part D-covered vaccine. In other words, the negotiated price for a Part D vaccine will be comprised of the vaccine ingredient cost, a dispensing fee (if applicable), and a vaccine administration fee. This interpretation recognizes the intrinsic linkage that exists between the vaccine and its corresponding administration, since a beneficiary would never purchase a vaccine without the expectation that it would be administered.

In general, CMS believes that Part D vaccines, including the associated administration costs, should be billed on one claim for both in- and out-of-network situations. For example, if an in-network pharmacy dispenses and administers the vaccine in accordance with State law, the pharmacy would process a single claim to the Part D sponsor and collect from the enrollee any applicable cost-sharing on the vaccine and its administration. Alternatively, if a vaccine is administered out-of-network in a physician‟s office, the physician would provide the vaccine and its administration and then bill the beneficiary for the entire charge, including all components. The beneficiary would, in turn, submit a paper claim to the Part D sponsor for reimbursement for both the vaccine ingredient cost and administration fee. 

Medicare Part D Manual

How to bill the administration fee in the same claim as the vaccine

The following NCPDP fields must be populated to bill an admin fee in same transaction as vaccine

438     INCENTIVE AMOUNT SUBMITTED (Dollar amount of admin fee associated with vaccine)

439     REASON FOR SERVICE CODE (PH: Preventative Health)

440     PROFESSIONAL SERVICE CODE (MA: Medication Administered)

441     RESULT OF SERVICE CODE (3N: Medication Administered)

*check with software vendor for exact location of these fields (normally located with DUR and Override Codes)

Please note that the above NCPDP field codes are only to be completed on claims for both the dispensing and administration of covered vaccines.