Q&A: Claims with Influenza Code Getting Returned

October 19, 2016
Medicare Web

Q: The influenza virus vaccine represented by CPT® code 90674 (influenza virus vaccine, quadrivalent [ccIIV4], derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use) was approved under the Medicare program as of August 1. However, our claims are kicking back when we report the code. Has there been a change?

A: That code is effective as of August 1, 2016, for Medicare claims. However, CMS has a specific schedule for the processing of new HCPCS codes, so while a code is effective and a service is covered, it may not yet be billable. CMS will process this code on claims with dates of service on or after January 1, 2017.

CMS issued an transmittal on this topic September 30. The article provided two options for the MACs:

  1. Have providers hold the claims until the January release is implemented and can process the code
  2. Allow providers to report a not otherwise classified (NOC) code and submit the claims now

Check your individual MAC website, as MACs have begun issuing instructions to providers for submitting these claims. For example, National Government Services (NGS) and CGS are not allowing an NOC code and will return to the provider as an invalid code. Providers submitting claims to these MACs should hold these until the January release is implemented.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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