Roster Billing Requirements for Pneumococcal Pneumonia Vaccine PPV Claims by Armaggedon


									   Roster Billing Requirements for Pneumococcal Pneumonia
                     Vaccine (PPV) Claims

What is Roster billing?                                                                       •    FL42 Revenue codes
Roster billing is a simplified billing process that allows                                    •    FL44 HCPCs code
mass immunizers to complete one UB-04 claim form                                              •    FL46 Service units
with an attached list of immunized beneficiaries.                                             •    FL47 Total charges
                                                                                              •    FL50 Payer
What type of bills can be used for roster billing?                                            •    FL51 Health Plan ID
                                                                                              •    FL56 Provider NPI (see attached roster)
12x, 13x, 22x, 23x, 72x, 74x, 75x, 85x                                                        •    FL67 Principal diagnosis
                                                                                              •    FL76 Attending Physician ID
What must a Roster contain?
     •    Provider name and NPI                                                          How many immunizations are required in one
     •    Date of service                                                                day to roster bill?
     •    Patient name and address
                                                                                         To qualify for roster billing, immunizations of at
     •    Patient date of birth
                                                                                         least five beneficiaries on the same date are
     •    Patient sex                                                                    required. This requirement is waived only when
     •    Patient health insurance claim number                                          vaccines are provided to hospital inpatients.
     •    Beneficiary signature or stamped “signature on                                 Therefore, their roster may contain fewer than five
          file                                                                           beneficiaries on the same day.
NOTE: A stamped "signature on file" can be used in place of the
beneficiary's actual signature for all institutional providers that
roster bill from an inpatient or outpatient department provided the                      PPV Roster Billing Quick Notes
provider has a signed authorization on file to bill Medicare for
services rendered. In this situation, they are not required to obtain                         •    FL17 Patient status 01
the patient signature on the roster. However, the provider has the
option of reporting "signature on file" in lieu of obtaining the                              •    FL18-28 Condition code A6 (no
patient's actual signature on the roster.                                                          coinsurance or deductible)
                                                                                              •    FL18-28 Condition code M1 (bypass for
In addition, for inpatient Part B services (12x and                                                MSP edits)
22x) the following data elements are also needed on                                           •    FL42 Revenue code 0636 (virus)
the roster:                                                                                   •    FL42 Revenue code 0771 (administration)
     •    Admission date                                                                      •    FL50 Payer “Medicare”
     •    Admission type                                                                      •    FL67 Diagnosis V03.82 (pneumonia)
     •    Admission diagnosis                                                                 •    FL76 The provider’s own NPI to be
     •    Admission source code                                                                    reported as the attending physician NPI.
     •    Patient status code                                                                 •    Roster claims must contain one single date
                                                                                                   of service.
What must the UB-04 claim form contain?                                                       •    Rural Health Clinics are not permitted to
                                                                                                   submit claims for PPV. Must bill service
     •    FL1 Facility name and address                                                            through cost report.
     •    FL4 Type of bill                                                                    •    Hospitals use type of bill 12x instead of
     •    FL6 Date of service                                                                      13x when roster billing for hospital
     •    FL8 Patient name(see attached roster)                                                    inpatients.
     •    FL17 Patient status                                                                 •    Must submit separate claim forms and
     •    FL18-28 Condition codes                                                                  rosters for PPV and influenza.

                                 TriSpan Health Services                  A CMS Contracted Intermediary
                                                     P. O. Box 23046 Jackson, MS 39225-3046
                                                  Hours of Operation: 8:00 AM – 4:30 PM, Monday – Friday
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The information contained in this fact sheet is provided as a customer service only. If any part of this information contradicts CMS regulations or US Code,
those sources will supersede the information contained here. Medicare laws and regulations change frequently, so it is important to be sure that you have the
most current fact sheet. This information was last updated 06/09/2008.                                                    Template Version 002, 2/1/2008
                                               FOR USE AS EXAMPLE ONLY

Vaccine Roster for Mass Immunizers

Provider Name:         ANY HOSPITAL

Provider Billing No:   XXXXXXXXXX

Date of Service:       06-09-08

 Patient’s Medicare                Patient’s Name
 Health Insurance Claim     Last        Last        MI             Patient Address           Sex    Birth          Signature
 Number                                                                                              Date
 111-11-1111A               DOE         JOHN        A    123 WILLOW ST. ANY TOWN, XX 55555   M     01-01-35   SIGNATURE ON FILE
 222-22-2222A               DOE         MARY        B    123 WILLOW ST. ANY TOWN, XX 55555   F     06-06-36   SIGNATURE ON FILE
 333-33-3333A               LEE         MIKE        C    246 SUNNY DR. ANY TOWN, XX 55555    M     04-21-35   SIGNATURE ON FILE
 444-44-4444B               LEE         SUE         D    246 SUNNY DR. ANY TOWN, XX 55555    F     03-15-36   SIGNATURE ON FILE
 555-55-5555A               DREW        JOHN        E    489 BIRD LN. ANY TOWN, XX 55555     M     02-17-35   SIGNATURE ON FILE

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