LCD Reference Article Billing and Coding Article

Billing and Coding: Billing Limitations for Pharmacies

A56124

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56124
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Billing Limitations for Pharmacies
Article Type
Billing and Coding
Original Effective Date
10/22/2018
Revision Effective Date
10/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

Medicare Part B has limitations on pharmacy billing. There are two “Specialty codes” that may be used by pharmacies, each with limitations.

Specialty 73 is for “Mass Immunization Roster Billers” and Specialty A5 (formerly Specialty 87) is for “Pharmacy”.

Specialty 73 may only bill for influenza or pneumococcal immunizations and their administration codes.

Specialty A5 may only bill for patient supplies of hemophilia factor products. Mass Immunizers must roster bill assigned claims and may only bill for immunizations.

Neither specialty 73 nor A5 may bill for drugs that are administered “incident to” a physician service; these must be billed by the physician. Also, none of these may bill for hepatitis B vaccine since this requires a physician order. Suppliers of oral immunosuppressive drugs, oral anti-cancer drugs, oral anti-nausea drugs and diabetes testing supplies must be enrolled as DME suppliers and submit their bills to the DME MAC.

Beginning October 22, 2018 only these codes will be allowed when billed by these specialties.

  • Specialty 73 - Mass Immunizers
    • Influenza Vaccine
      • 90653-90668, 90630, 90672-90674, 90682-90689, 90756
      • not all are currently active/available; see annual Change Request (CR).
    • Pneumococcal Vaccine
      • 90670, 90732
    • Vaccine Administration
      • G0008, G0009
    • Specialty A5 - Pharmacy
      • Hemophilia Clotting Factors (J7170, J7180-J7195, J7198-J7212, J7214)
      • Certain other suppliers are also enrolled as Specialty A5 such as Cochlear Implant suppliers.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(52 Codes)
Group 1 Paragraph

 

 

 

 

Group 1 Codes
Code Description
90630 INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, PRESERVATIVE FREE, FOR INTRADERMAL USE
90653 INFLUENZA VACCINE, INACTIVATED (IIV), SUBUNIT, ADJUVANTED, FOR INTRAMUSCULAR USE
90654 INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE-FREE, FOR INTRADERMAL USE
90655 INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE
90656 INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE
90657 INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE
90658 INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE
90660 INFLUENZA VIRUS VACCINE, TRIVALENT, LIVE (LAIV3), FOR INTRANASAL USE
90661 INFLUENZA VIRUS VACCINE, TRIVALENT (CCIIV3), DERIVED FROM CELL CULTURES, SUBUNIT, PRESERVATIVE AND ANTIBIOTIC FREE, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE
90662 INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE
90664 INFLUENZA VIRUS VACCINE, LIVE (LAIV), PANDEMIC FORMULATION, FOR INTRANASAL USE
90666 INFLUENZA VIRUS VACCINE (IIV), PANDEMIC FORMULATION, SPLIT VIRUS, PRESERVATIVE FREE, FOR INTRAMUSCULAR USE
90667 INFLUENZA VIRUS VACCINE (IIV), PANDEMIC FORMULATION, SPLIT VIRUS, ADJUVANTED, FOR INTRAMUSCULAR USE
90668 INFLUENZA VIRUS VACCINE (IIV), PANDEMIC FORMULATION, SPLIT VIRUS, FOR INTRAMUSCULAR USE
90670 PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE
90672 INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LAIV4), FOR INTRANASAL USE
90673 INFLUENZA VIRUS VACCINE, TRIVALENT (RIV3), DERIVED FROM RECOMBINANT DNA, HEMAGGLUTININ (HA) PROTEIN ONLY, PRESERVATIVE AND ANTIBIOTIC FREE, FOR INTRAMUSCULAR USE
90674 INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), DERIVED FROM CELL CULTURES, SUBUNIT, PRESERVATIVE AND ANTIBIOTIC FREE, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE
90682 INFLUENZA VIRUS VACCINE, QUADRIVALENT (RIV4), DERIVED FROM RECOMBINANT DNA, HEMAGGLUTININ (HA) PROTEIN ONLY, PRESERVATIVE AND ANTIBIOTIC FREE, FOR INTRAMUSCULAR USE
90685 INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE
90686 INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, PRESERVATIVE FREE, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE
90687 INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE
90688 INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE
90689 INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), INACTIVATED, ADJUVANTED, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE
90732 PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE
90756 INFLUENZA VIRUS VACCINE, QUADRIVALENT (CCIIV4), DERIVED FROM CELL CULTURES, SUBUNIT, ANTIBIOTIC FREE, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE
G0008 ADMINISTRATION OF INFLUENZA VIRUS VACCINE
G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE
J7170 INJECTION, EMICIZUMAB-KXWH, 0.5 MG
J7180 INJECTION, FACTOR XIII (ANTIHEMOPHILIC FACTOR, HUMAN), 1 I.U.
J7181 INJECTION, FACTOR XIII A-SUBUNIT, (RECOMBINANT), PER IU
J7182 INJECTION, FACTOR VIII, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (NOVOEIGHT), PER IU
J7183 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, 1 I.U. VWF:RCO
J7185 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I.U.
J7186 INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN), PER FACTOR VIII I.U.
J7187 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCO
J7188 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (OBIZUR), PER I.U.
J7189 FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (NOVOSEVEN RT), 1 MICROGRAM
J7190 FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.
J7191 FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U.
J7192 FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISE SPECIFIED
J7193 FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.
J7194 FACTOR IX, COMPLEX, PER I.U.
J7195 INJECTION, FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER IU, NOT OTHERWISE SPECIFIED
J7198 ANTI-INHIBITOR, PER I.U.
J7199 HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED
J7200 INJECTION, FACTOR IX, (ANTIHEMOPHILIC FACTOR, RECOMBINANT), RIXUBIS, PER IU
J7201 INJECTION, FACTOR IX, FC FUSION PROTEIN, (RECOMBINANT), ALPROLIX, 1 I.U.
J7202 INJECTION, FACTOR IX, ALBUMIN FUSION PROTEIN, (RECOMBINANT), IDELVION, 1 I.U.
J7205 INJECTION, FACTOR VIII FC FUSION PROTEIN (RECOMBINANT), PER IU
J7212 FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT)-JNCW (SEVENFACT), 1 MICROGRAM
J7214 INJECTION, FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX, RECOMBINANT (ALTUVIIIO), PER FACTOR VIII I.U.
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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
999x Not Applicable
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2023 R6

Updated to indicate this article is not an LCD Reference Article.

10/01/2023 R5

Per Quarterly CPT/HCPCS updates:

The following code was added to the Group 1 Codes: J7214

The Article Text was updated to add J7214 under the Specialty A5 – Pharmacy Hemophilia Clotting Factors section.

01/01/2021 R4

Per 2021 CPT updates, added J7212 to the narrative and to the Group 1 list of CPT codes.

The following CPT codes had description changes in Group 1:

90653, 90655, 90656, 90661, 90662, 90666, 90667, 90672, 90674, 90682, 90685, 90686, 90687, 90688, 90756, J7189.

01/01/2019 R3

Article converted to Billing and Coding, no changes in coverage were made.

01/01/2019 R2

Per 2019 CPT Updates, added 96089 and J7170 to the narrative and Group 1 list of CPT Codes effective 01/01/2019. Q9995 is deleted effective 12/31/18 per 2019 CPT Updates.

10/22/2018 R1

10/29/2018: At this time 21st Century Cures Act will apply to new and revised Local Coverage Articles that restrict coverage which requires comment and notice.  This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the Article are applicable as noted in this policy.

Typographical Error Corrected in Coding: 96053 and 96054 corrected to 90653 and 90654 in CPT Group I Coding.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Updated On Effective Dates Status
11/08/2023 10/01/2023 - N/A Currently in Effect You are here
09/15/2023 10/01/2023 - N/A Superseded View
01/28/2021 01/01/2021 - 09/30/2023 Superseded View
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Keywords

  • Specialty
  • Pharmacy
  • A5
  • 73
  • Mass Immunization Roster Billers
  • limitations
  • 90630
  • 90653
  • 90654
  • 90655
  • 90656
  • 90657
  • 90658
  • 90660
  • 90661
  • 90662
  • 90664
  • 90666
  • 90667
  • 90668
  • 90670
  • 90672
  • 90673
  • 90674
  • 90682
  • 90685
  • 90686
  • 90687
  • 90688
  • 90689
  • 90732
  • 90756
  • G0008
  • G0009
  • J7170
  • J7180
  • J7181
  • J7182
  • J7183
  • J7185
  • J7186
  • J7187
  • J7188
  • J7189
  • J7190
  • J7191
  • J7192
  • J7193
  • J7194
  • J7195
  • J7198
  • J7199
  • J7200
  • J7201
  • J7202
  • J7205
  • J7212