No Joy --> Administration Fee for Zostavax kaput

[Guest guest]

Pointed out on the list that the 2007 G-code to administer Zostavax is no longer valid.

I used the G0377 on a couple patients (Medicare patients that picked up the Zostavax from a Medicare Part D pharmacy and brought it to the office for us to give).

But now I'm confused...the guidelines below/attached say...rather you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement.

My understanding was that you had to be a Medicare Part D pharmacy to get reimbursed for the Zostavax.

Also, does this mean we charge the patient directly -- they pay cash -- and then they are responsible for submitting to Part D for the administration fee?

Very confusing.

I wish I understood more about how the patient is supposed to get the vaccine.

Cost at drugstore.com is...

Zostavax (other types of Zostavax)

Zostavax - 19400unt/0.65ml Solution Vial

Quantity

Our Price

1 vial

$192.99

3 vials

$576.95 - save 4% ($23.38)

9 vials

$1,715.96 - save 5% ($85.03)

A little cheaper at Besse.com

28146

ZOSTAVAX SDV 0.65ML W/DILUENT - APPROX. 3-5 DAYS TO SHIP MERCK & CO. INC. DROPSHIP-MERCK $20 FEE FOR ORDERS LESS THAN 4 DOSES

N00006-4963-00

Each

$171.92

Anyone with success on getting this vaccine for patients and billing for the administration in 2008 -- it's early, so probably nobody has been paid yet.

Locke, MD

==============================================================================

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0723.pdf

This article (Special Edition (SE) 0723) provides 2008 payment guidance for the administration of Part D-covered vaccines. This is not new policy guidance, just a reminder of the policy for 2008. Remember that, effective January 1, 2008, physicians can no longer bill Medicare Part B for the administration of Medicare Part D-covered vaccines, using the special G code (G0377). Instead, you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to their Part D plan for reimbursement

You should make sure that your billing staffs are aware of this Part D-covered vaccine administration guidance for 2008.

Section 202( of the Tax Relief and Health Care Act of 2006 (TRHCA) established a permanent policy for payment by Medicare for administration of Part D-covered vaccines, beginning in 2008. Specifically, the policy states that, effective January 1, 2008, the administration of a Part D-covered vaccine is included in the definition of "covered Part D drug" under the Part D statute.

During 2007, in transition to this new policy, providers were permitted to bill Part B for the administration of a Part D vaccine using a special G code (G0377). SE0723 now reminds providers of the requirement that payment for the administration of Part D covered vaccines only during 2007.

Therefore, effective January 1, 2008, you can no longer bill the G code to Part B; rather you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement.

Important Note: This guidance does not affect Part B covered vaccines.

=================================

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5459.pdf

As a result of the Tax Relief and Health Care Act of 2006, effective January 1, 2007, G0377 (Administration of vaccine for Part D drug) is added to the MPFS with a status indicator of X. Payment for HCPCS code G0377 is linked to CPT code 90471 (just as payment is made for G0008, G0009, and G0010). For 2007 only, the legislation provides for Part B to pay for the administration of a covered Part D vaccine. When a physician administers a Part D vaccine, the physician should use G0377 to bill the local carrier for the administration of the vaccine. Payment to the physician will be on an assigned basis only. Normal beneficiary deductible and coinsurance requirements apply to this administration. Payment for Part D covered vaccines is made solely by the participating Prescription Drug Plan. Medicare will not pay for the vaccine itself.

Here was the original guidline...

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5486.pdf

Specifically, effective January 1, 2008, the administration of a Part D-covered vaccine is included in the definition of "covered Part D drug" under the Part D statute. Until this effective date, Section 202(a) of TRHCA provides for a transition policy (in effect for 2007 only) which permits payment under Medicare Part B for administration of a Part D-covered vaccine. For this 2007 transition period, payment will be made under Part B for the administration of a covered Part D vaccine "as if it were the administration of a vaccine described in section 1861(s)(10)( [hepatitis B vaccine.]"

Since payment for administration of a hepatitis B vaccine requires the application of Part B coinsurance and deductible, and involves other statutory requirements such as assignment; these requirements also apply (during 2007) to a payment for the administration of a Part D-covered vaccine. Moreover, payment under Part B for administration of a Part D-covered vaccine is available only if 1) On the date of service, the pharmacy is enrolled as such with the National Supplier Clearinghouse; and 2) The Medicare beneficiary, to whom the Part D-covered vaccine is furnished, is enrolled in a Part D Prescription Drug Plan.

Here are some details that you should know:

1. Neither this CR nor CR 5459 addresses payment for a Part D-covered vaccine itself. Payment for Part D-covered vaccines is made solely by participating Part D Prescription Drug Plans.

2. You should use G code (G0377: Administration of vaccine for Part D drug) for the administration of Part D-covered vaccines in 2007. The Part B allowed charge for this code (effective for 2007) is $19.33. Thus, the Medicare payment would be 80% of that amount or $15.46, assuming the beneficiary’s Part B deductible is met. The beneficiary would pay $3.87 as a coinsurance payment, plus any Part B deductible payment that may be due.

3. Claims must be submitted in the 837 or the CMS 1500 paper form, billed with Indicator 05 –Pharmacy, and indicating the Place of Service (POS) as either home or pharmacy.

4. The Administration of Part D vaccine claims is subject to mandatory assignment. Your DMERC/DME MACs will therefore ensure that you accept assignment for claims associated with the administration of a Part D vaccine; and if you should submit a claim for G0377 as unassigned, will process that claim as though it were assigned. Further, since beneficiaries can not submit

assigned claims, beneficiary-submitted claims for the administration under the Tax Relief and Health Care Act of 2006 legislation can not be paid.

5. You must retain in your records the physician orders/prescription of record for claims associated with the administration a Part D vaccine.

6. DMERCs/DME MACs will return/reject claims for the administration of a Part D vaccine with dates of service after December 31, 2007, and they will use existing Medicare Summary Notice and remittance advice messages for claims associated with the administration of a vaccine.

7. Note that the implementation date for this change is January 29, 2007 in Medicare systems. Thus, your DMERC or DME MAC may not actually process any 2007 claims for payment until that date.

[Guest guest]

,

Because this has been so confusing, my policy has been to have my Medicare patients sign an ABN (because NOBODY knows who is supposed to pay for what), have the patient pay me in full at the time the vaccination is given, then submit to Medicare, where it is rejected and then sent on to the secondary where it is sporadically reimbursed by the secondaries (I think they are confused also). Because I am nonparticipating with Medicare, most of the secondary checks are sent directly to the patient, so they are reimbursed what ever the secondary decided the vaccine was worth.

Lawmakers must clear up this confusion, but we all know they won't.

All of this is pushing me WAY toward opting out of Medicare at the end of 2008. Not offering the shingles vaccine to my patient population is bad medicine. The thought of going to jail because I need to be paid for administering and keeping the vaccine, but possibly inadvertently incorrectly billing for it, makes me want to throw up.

Durango, CO

Pointed out on the list that the 2007 G-code to administer Zostavax is no longer valid.

I used the G0377 on a couple patients (Medicare patients that picked up the Zostavax from a Medicare Part D pharmacy and brought it to the office for us to give).

But now I'm confused...the guidelines below/attached say...rather you will need to bill the patient for the

vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement.

My understanding was that you had to be a Medicare Part D pharmacy to get reimbursed for the Zostavax.

Also, does this mean we charge the patient directly -- they pay cash -- and then they are responsible for submitting to Part D for the administration fee?

Very confusing.

I wish I understood more about how the patient is supposed to get the vaccine.

Cost at drugstore.com is...

Zostavax (other types of Zostavax

)

Zostavax -

19400unt/0.65ml Solution Vial

Quantity

Our Price

1 vial

$192.99

3 vials

$576.95 - save 4% ($23.38)

9 vials

$1,715.96 - save 5% ($85.03)

A little cheaper at Besse.com

28146

ZOSTAVAX SDV 0.65ML W/DILUENT - APPROX. 3-5 DAYS TO SHIP MERCK & CO. INC. DROPSHIP-MERCK $20 FEE FOR ORDERS LESS THAN 4 DOSES

N00006-4963-00

Each

$171.92

Anyone with success on getting this vaccine for patients and billing for the administration in 2008 -- it's early, so probably nobody has been paid yet.

Locke, MD

==============================================================================

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0723.pdf

This article (Special Edition (SE) 0723) provides 2008 payment guidance for the administration of Part D-covered vaccines. This is not new policy guidance, just a reminder of the policy for 2008.

Remember that, effective January 1, 2008, physicians can no longer bill Medicare Part B for the administration of Medicare Part D-covered vaccines, using the special G code (G0377). Instead, you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to their Part D plan for reimbursement

You should make sure that your billing staffs are aware of this Part D-covered vaccine administration guidance for 2008.

Section 202( of the Tax Relief and Health Care Act of 2006 (TRHCA) established a permanent policy for payment by Medicare for administration of Part D-covered vaccines, beginning in 2008. Specifically, the policy states that, effective January 1, 2008, the administration of a Part D-covered vaccine is included in the definition of " covered Part D drug " under the Part D statute.

During 2007, in transition to this new policy, providers were permitted to bill Part B for the administration of a Part D vaccine using a special G code (G0377). SE0723 now reminds providers of the requirement that payment for the administration of Part D covered vaccines only during 2007.

Therefore, effective January 1, 2008, you can no longer bill the G code to Part B; rather you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement.

Important Note: This guidance does not affect Part B covered vaccines.

=================================

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5459.pdf

As a result of the Tax Relief and Health Care Act of 2006, effective January 1, 2007, G0377 (Administration of vaccine for Part D drug) is added to the MPFS with a status indicator of X. Payment for HCPCS code G0377 is linked to CPT code 90471 (just as payment is made for G0008, G0009, and G0010). For 2007 only, the legislation provides for Part B to pay for the administration of a covered Part D vaccine. When a physician administers a Part D vaccine, the physician should use G0377 to bill the local carrier for the administration of the vaccine. Payment to the physician will be on an assigned basis only. Normal beneficiary deductible and coinsurance requirements apply to this administration. Payment for Part D covered vaccines is made solely by the participating Prescription Drug Plan. Medicare will not pay for the vaccine itself.

Here was the original guidline...

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5486.pdf

Specifically, effective January 1, 2008, the administration of a Part D-covered vaccine is included in the definition of " covered Part D drug " under the Part D statute. Until this effective date, Section 202(a) of TRHCA provides for a transition policy (

in effect for 2007 only) which permits payment under Medicare Part B for administration of a Part D-covered vaccine. For this 2007 transition period, payment will be made under Part B for the administration of a covered Part D vaccine " as if it were the administration of a vaccine described in section 1861(s)(10)( [hepatitis B vaccine.] " Since payment for administration of a hepatitis B vaccine requires the application of Part B coinsurance and deductible, and involves other statutory requirements such as assignment; these requirements also apply (during 2007) to a payment for the administration of a Part D-covered vaccine. Moreover, payment under Part B for administration of a Part D-covered vaccine is available only if 1) On the date of service, the pharmacy is enrolled as such with the National Supplier Clearinghouse; and 2) The Medicare beneficiary, to whom the Part D-covered vaccine is furnished, is enrolled in a Part D Prescription Drug Plan.

Here are some details that you should know:

1. Neither this CR nor CR 5459 addresses payment for a Part D-covered vaccine itself. Payment for Part D-covered vaccines is made solely by participating Part D Prescription Drug Plans.

2. You should use G code (G0377: Administration of vaccine for Part D drug) for the administration of Part D-covered vaccines in 2007. The Part B allowed charge for this code (effective for 2007) is $19.33. Thus, the Medicare payment would be 80% of that amount or $15.46, assuming the beneficiary's Part B deductible is met. The beneficiary would pay $3.87 as a coinsurance payment, plus any Part B deductible payment that may be due.

3. Claims must be submitted in the 837 or the CMS 1500 paper form, billed with Indicator 05 –Pharmacy, and indicating the Place of Service (POS) as either home or pharmacy.

4. The Administration of Part D vaccine claims is subject to mandatory assignment. Your DMERC/DME MACs will therefore ensure that you accept assignment for claims associated with the administration of a Part D vaccine; and if you should submit a claim for G0377 as unassigned, will process that claim as though it were assigned. Further, since beneficiaries can not submit

assigned claims, beneficiary-submitted claims for the administration under the Tax Relief and Health Care Act of 2006 legislation can not be paid.

5. You must retain in your records the physician orders/prescription of record for claims associated with the administration a Part D vaccine.

6. DMERCs/DME MACs will return/reject claims for the administration of a Part D vaccine with dates of service after December 31, 2007, and they will use existing Medicare Summary Notice and remittance advice messages for claims associated with the administration of a vaccine.

7. Note that the implementation date for this change is January 29, 2007 in Medicare systems. Thus, your DMERC or DME MAC may not actually process any 2007 claims for payment until that date.

[Guest guest]

The shingles vaccine is our first vaccine developed since Medicare Part B, hence the fun. Every Medicare plan is handling it differently in my area. BCBS are reimbursing, though probably at lower than my cost.Two local plans are reimbursing. United might be. . .Most of my patients are willing to pay me up front while I sort the mess out with each payer (non-payer). Has anyone else read the data that say this vaccine is only 50% effective?What's the take of the more scientific folks on it? Pointed out on the list that the 2007 G-code to administer Zostavax is no longer valid.   I used the G0377 on a couple patients (Medicare patients that picked up the Zostavax from a Medicare Part D pharmacy and brought it to the office for us to give).   But now I'm confused...the guidelines below/attached say...rather you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement.   My understanding was that you had to be a Medicare Part D pharmacy to get reimbursed for the Zostavax.   Also, does this mean we charge the patient directly -- they pay cash -- and then they are responsible for submitting to Part D for the administration fee?   Very confusing.   I wish I understood more about how the patient is supposed to get the vaccine.   Cost at drugstore.com is...   Zostavax (other types of Zostavax) Zostavax - 19400unt/0.65ml Solution Vial Quantity Our Price 1 vial $192.99 3 vials $576.95 - save 4% ($23.38) 9 vials $1,715.96 - save 5% ($85.03)   A little cheaper at Besse.com   28146     ZOSTAVAX SDV 0.65ML W/DILUENT - APPROX. 3-5 DAYS TO SHIP MERCK & CO. INC. DROPSHIP-MERCK $20 FEE FOR ORDERS LESS THAN 4 DOSES N00006-4963-00  Each $171.92         Anyone with success on getting this vaccine for patients and billing for the administration in 2008 -- it's early, so probably nobody has been paid yet.   Locke, MD ==============================================================================       http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0723.pdf   This article (Special Edition (SE) 0723) provides 2008 payment guidance for the administration of Part D-covered vaccines. This is not new policy guidance, just a reminder of the policy for 2008. Remember that, effective January 1, 2008, physicians can no longer bill Medicare Part B for the administration of Medicare Part D-covered vaccines, using the special G code (G0377). Instead, you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to their Part D plan for reimbursement You should make sure that your billing staffs are aware of this Part D-covered vaccine administration guidance for 2008. Section 202( of the Tax Relief and Health Care Act of 2006 (TRHCA) established a permanent policy for payment by Medicare for administration of Part D-covered vaccines, beginning in 2008. Specifically, the policy states that, effective January 1, 2008, the administration of a Part D-covered vaccine is included in the definition of "covered Part D drug" under the Part D statute. During 2007, in transition to this new policy, providers were permitted to bill Part B for the administration of a Part D vaccine using a special G code (G0377). SE0723 now reminds providers of the requirement that payment for the administration of Part D covered vaccines only during 2007. Therefore, effective January 1, 2008, you can no longer bill the G code to Part B; rather you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement. Important Note: This guidance does not affect Part B covered vaccines.  =================================http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5459.pdf As a result of the Tax Relief and Health Care Act of 2006, effective January 1, 2007, G0377 (Administration of vaccine for Part D drug) is added to the MPFS with a status indicator of X. Payment for HCPCS code G0377 is linked to CPT code 90471 (just as payment is made for G0008, G0009, and G0010). For 2007 only, the legislation provides for Part B to pay for the administration of a covered Part D vaccine. When a physician administers a Part D vaccine, the physician should use G0377 to bill the local carrier for the administration of the vaccine. Payment to the physician will be on an assigned basis only. Normal beneficiary deductible and coinsurance requirements apply to this administration. Payment for Part D covered vaccines is made solely by the participating Prescription Drug Plan. Medicare will not pay for the vaccine itself. Here was the original guidline...http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5486.pdf Specifically, effective January 1, 2008, the administration of a Part D-covered vaccine is included in the definition of "covered Part D drug" under the Part D statute. Until this effective date, Section 202(a) of TRHCA provides for a transition policy (in effect for 2007 only) which permits payment under Medicare Part B for administration of a Part D-covered vaccine. For this 2007 transition period, payment will be made under Part B for the administration of a covered Part D vaccine "as if it were the administration of a vaccine described in section 1861(s)(10)( [hepatitis B vaccine.]" Since payment for administration of a hepatitis B vaccine requires the application of Part B coinsurance and deductible, and involves other statutory requirements such as assignment; these requirements also apply (during 2007) to a payment for the administration of a Part D-covered vaccine. Moreover, payment under Part B for administration of a Part D-covered vaccine is available only if 1) On the date of service, the pharmacy is enrolled as such with the National Supplier Clearinghouse; and 2) The Medicare beneficiary, to whom the Part D-covered vaccine is furnished, is enrolled in a Part D Prescription Drug Plan. Here are some details that you should know: 1. Neither this CR nor CR 5459 addresses payment for a Part D-covered vaccine itself. Payment for Part D-covered vaccines is made solely by participating Part D Prescription Drug Plans. 2. You should use G code (G0377: Administration of vaccine for Part D drug) for the administration of Part D-covered vaccines in 2007. The Part B allowed charge for this code (effective for 2007) is $19.33. Thus, the Medicare payment would be 80% of that amount or $15.46, assuming the beneficiary’s Part B deductible is met. The beneficiary would pay $3.87 as a coinsurance payment, plus any Part B deductible payment that may be due. 3. Claims must be submitted in the 837 or the CMS 1500 paper form, billed with Indicator 05 –Pharmacy, and indicating the Place of Service (POS) as either home or pharmacy. 4. The Administration of Part D vaccine claims is subject to mandatory assignment. Your DMERC/DME MACs will therefore ensure that you accept assignment for claims associated with the administration of a Part D vaccine; and if you should submit a claim for G0377 as unassigned, will process that claim as though it were assigned. Further, since beneficiaries can not submit assigned claims, beneficiary-submitted claims for the administration under the Tax Relief and Health Care Act of 2006 legislation can not be paid. 5. You must retain in your records the physician orders/prescription of record for claims associated with the administration a Part D vaccine. 6. DMERCs/DME MACs will return/reject claims for the administration of a Part D vaccine with dates of service after December 31, 2007, and they will use existing Medicare Summary Notice and remittance advice messages for claims associated with the administration of a vaccine. 7. Note that the implementation date for this change is January 29, 2007 in Medicare systems. Thus, your DMERC or DME MAC may not actually process any 2007 claims for payment until that date.     <28146_small.jpg><alternates_minus.gif><SE0723.pdf>

[Guest guest]

My policy is to let the patient know what is the cost from Merck including the shipping, they pay us, we order and administer. We give them the invoice/receipt, they send it to their plan. No direct expense for me, minor time expense and so far, appreciative patients.

We plan to submit a bill for the therapeutic administration of medication, I am just providing a service to my patient and hopefully prevent a painful and debilitating herpetic neuralgia (have done 3, don't know if Medicare has paid anything yet!).

The best guidance is to put oneself in the patient's position, how would I like to be treated as the patient/client?-- Pedro Ballester, M.D.Warren, OH