Flu shot update from Tricare – CPT Q2035,Q2036,Q2038 & 90655, 90656,90660

by | Oct 21, 2011 | CPT modifiers

2011-2012 Billing for Flu Shots

Upon direction from TRICARE Management Activity (TMA), TriWest Healthcare Alliance (TriWest) will be following the latest Centers for Medicare & Medicaid Services’ billing guidelines for the 2011-2012 flu season. The change is retroactive to January 1, 2011.
The following Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes are recommended for billing. There is currently CHAMPUS Maximum Allowable Charge (CMAC) pricing for these codes:

  • 90655 – Influenza virus vaccine, split virus, preservative free, when administered to children 6-o35 mnths of age for intramuscular use 
  • 90656 – Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older for intramuscular use 
  • 90657 – Influenza virus vaccine, split virus, when administered to children 6-35 months of age for intramuscular use 
  • 90660 – Influenza virus vaccine, live, for intranasal use 
  • Q2035 – Influenza virus, spit virus, when administered to individuals 3 years of age and older for intramuscular use (Afluria) 
  • Q2036 – Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older for intramuscular use (Fluaval) 
  • Q2038 – Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older for intramuscular use (Fluzone)

CPT code 90658 (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older for intramuscular use) is currently not priced by TRICARE®. If this code is used for billing, the claim must be billed with the National Drug Code (NDC) number and it will be reimbursed at the NDC rate. If there is no NDC on the claim, it will be denied. If the 90658 is denied and an Q-code is appropriate, a corrected claim can be submitted.
Note: 90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content for intramuscular use is on the No Government Pay Procedure Code List and is not reimbursable.