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Upcoming Changes to Medicare Vaccine Billing

Synergy Billing Feb 18, 2025 11:51:23 AM

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Effective July 1, 2025, Medicare Will Transition FQHC Vaccine Billing from Cost Reports to Claim-Based Reimbursement

Federally Qualified Health Centers (FQHCs) are facing a major change in how they bill Medicare for preventive vaccines. Starting July 1, 2025, the reimbursement process will shift from cost-report-based payments to claim-based billing under Medicare Part B. This transition represents a significant operational and financial shift for FQHC executives, requiring new billing workflows, system updates, and staff training.

Key Changes at a Glance

Vaccines will be billed on an institutional claim (UB-04) using standard HCPCS/CPT codes.
No qualifying visit is required—vaccines will not be included in the all-inclusive rate (AIR) or Prospective Payment System (PPS) reimbursement.
Reimbursement will be separate under Medicare Part B, shifting from the traditional cost report model.
COVID-19 vaccines will have Medicare-determined rates, while other vaccines will be reimbursed at 95% of the Average Wholesale Price (AWP).

Billing Requirements & Codes

FQHCs must submit vaccine claims separately, using the following HCPCS/CPT codes:

Vaccine Product Codes & Reimbursement

Vaccine Type	HCPCS/CPT Codes	Reimbursement Method
Influenza Vaccine	90630, 90653, 90654, etc.	95% of AWP
Pneumococcal Vaccine	90670, 90732	95% of AWP
Hepatitis B Vaccine	90739, 90740, 90746, etc.	95% of AWP
COVID-19 Vaccine	Varies by brand	Medicare-determined rate

Vaccine Administration Codes

Administration Code	Description
G0008	Influenza vaccine administration
G0009	Pneumococcal vaccine administration
G0010	Hepatitis B vaccine administration
COVID-19 Codes	Vary by dose and vaccine type

What This Means for FQHC Executives

This transition requires careful planning to avoid reimbursement delays and compliance risks. FQHC leaders must ensure their teams are prepared for claim-based billing and update internal systems accordingly. Key areas to address:

Electronic Health Record (EHR) & Billing System Updates
- Ensure your system correctly excludes vaccines from AIR/PPS calculations and applies the correct HCPCS/CPT codes and AWP-based pricing.
- Verify that billing platforms can handle standalone vaccine claims under Medicare Part B.
Staff Training & Compliance
- Educate billing teams on the shift from cost-report-based to claim-based vaccine billing.
- Train staff to properly submit UB-04 claims with the appropriate vaccine and administration codes.
Financial Impact Analysis
- The change may impact FQHC revenue streams. Conduct a financial review to model how this shift will affect vaccine-related reimbursement.
- Monitor Medicare updates on COVID-19 vaccine payment rates to avoid revenue disruptions.

How Synergy Billing Can Help

Navigating these changes can be complex, but Synergy Billing is here to support FQHCs through this transition. Our team of experts is prepared to help ensure that your billing systems, workflows, and teams are ready for the shift to claim-based reimbursement.

We offer a free 'Ask the Expert' resource where FQHC executives and billing teams can get personalized guidance on how to implement these changes. If you have any questions about setting up your system or properly billing for vaccines, contact Synergy Billing’s 'Ask the Expert' service today.

📩 Get Expert Help – Reach out to us at 877-242-8475 or request help below to ensure a smooth transition before July 1, 2025.

Stay ahead of the changes and make sure your FQHC is prepared for Medicare’s new vaccine billing requirements!