Billing and Coding: Billing Limitations for Pharmacies

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 90612, 90613, 90653, 90655-90658, 90660-90662, 90664, 90666-90668, 90635, 90637-90638, 90672-90674, 90682-90689, 90695, 90756 not all are currently active/available; see annual Change Request (CR). Pneumococcal Vaccine 90670, 90684, 90732 Vaccine Administration G0008, G0009 Specialty A5 - Pharmacy Hemophilia Clotting Factors (J7170, J7180-J7183, J7185-J7195, J7198-J7205, J7207-J7212, J7214) Certain other suppliers are also enrolled as Specialty A5 such as Cochlear Implant suppliers.