Vaccine Reimbursement Guidelines for Home Health Agencies
September 22, 2015 07:08 AM
As agencies gear up for the 2015-2016 influenza season, questions often arise regarding the reimbursement rates for providing the flu vaccine to patients and the community.
There are two payment rates agencies must consider when providing vaccines: payment for the vaccine itself and payment to administer the vaccine.
Home health agencies (HHA) are reimbursed for the vaccine on a reasonable cost basis. Other than application of the lower costs or charges provision, Medicare recognizes the reasonable, allowable cost for the vaccine.
If, however, an HHA’s intermediary believes that the HHA has unreasonably incurred cost for the vaccines—or otherwise has not been a prudent buyer—it is up to the HHA to support that it was prudent and that the costs are reasonable. If it cannot, the intermediary will not recognize the unreasonable portion of the incurred cost.
Reimbursement for the vaccine administration for home health agencies is based on the outpatient prospective payment system (OPPS) vaccine administration rate, which is determined each calendar year (CY). Sixty percent of the rate is wage adjusted using the hospital wage index for the core based statistical area (CBSA) where the service is provided. The 2015 OPPS rate for the influenza vaccine administration is $32.57.
To determine the amount the HHA will be reimbursed for the vaccine administration, the agency will need to use the hospital wage index that applies to the CBSA where the service is furnished and adjust 60 percent of the national unadjusted payment for vaccine administration by the applicable wage index.
For example, the 2015 national unadjusted payment rate is $32.57. If the hospital wage index for the applicable CBSA is .99, payment to the HHA will be $32.37:
$32.57*.6 = $19.542 (the portion to be wage adjusted);
$19.542 *.99 (the wage index) =$19.34658 (the wage adjusted portion of the payment);
$19.34658 + $13.028 (the 40% of the national unadjusted payment that is not wage adjusted) = $32.37 (after rounding).
NOTE: ICD-10-CM diagnosis code Z23 may be used for an encounter for immunizations effective with the implementation of ICD-10.
Click herefor the Medlearn Matters “QUICK REFERENCE INFORMATION: Medicare Immunization Billing” for influenza vaccine and vaccine administration billing codes.