As fall and winter approach, the risk of respiratory illnesses such as influenza increases for patients of all ages. Health care systems play a critical role in protecting communities by facilitating timely immunizations, which help reduce illness severity, minimize missed work and school days and lower hospitalization rates. Preventive measures — including hand hygiene, cleaning frequently touched surfaces and encouraging patients to stay home when ill —remain essential strategies to limit the spread of respiratory illnesses.
BCBSND Expectations and Billing Guidance:
Immunizations are widely available from various provider types. As a payer, BCBSND reminds health care systems of the importance of verifying member eligibility, benefits and applicable policies prior to rendering immunization services. This ensures accurate claims processing and compliance with payer requirements.
Billing Requirements:
- Immunizations such as influenza and pneumonia should be billed on a CMS 1500 claim form when submitted to BCBSND, even if administered to an inpatient member. For inpatient immunizations, use the CMS-1500 form with Place of Service (POS) code 21, as outlined in BCBSND’s inpatient immunizations reimbursement policy.
- For state-supplied vaccines, refer to the Modifier SL policy for correct billing procedures.
- Ensure that all claims reflect the appropriate diagnosis codes (e.g., ICD-10 Z23 for immunization encounters) and modifiers when required.
- When billing Influenza and COVID vaccines together, using administration codes: 90471 and 90480 providers should append the modifier 59.
- Roster billing is available for mass immunization programs, allowing providers to submit claims for multiple patients receiving the same vaccine on the same date. Each vaccine type should be billed on a separate roster bill, and only vaccine administration should be included.
Policy Compliance:
- Payment determination is subject to member benefits, provider participation agreements and routine claim editing logic, including payment integrity and medical necessity edits. Legislative or mandated criteria will always supersede payer policy.
Note: For providers who may have experienced issues with claim denials regarding CPT 90480, please see HealthCare News article Notification of Rejections for CPT Code 90480.
Questions?
For additional guidance, health care systems should contact the phone number listed on the back of the member’s ID card or refer to BCBSND’s provider policies and Commercial & Medicaid Expansion provider manuals for the latest updates.
