Q: I am the infection preventionist at my skilled care facility. How can I advise my office to order and bill for RSV vaccines? 

A: Many specialists and facilities are having difficulty implementing the ordering and billing of the RSV vaccines. They must be billed through your pharmacy provider.

I contacted David Gifford, MD, chief medical officer at the American Health Care Association, for some guidance on this important question.

Here’s his informative reply:

“RSV vaccine is covered by Part D and only covers the cost of the vaccine. Part D will cover the cost of RSV during a SNF Part A stay.  Part D includes the  administration fee as part of the Part D cost of the vaccine; unlike Part B for influenza that has a separate administration code and fee.”  

He noted this important distinction, too: “SNFs may NOT bill Part D for the vaccine. Only the pharmacies can bill Part D. So the SNF will need to talk with the pharmacy about how they will bill Part D just like they bill part D for all other medications — that is, they should not be charging the SNF when a person has Part D.”

About 20% of Medicare beneficiaries do not have Part D, Dr. Gifford added, and those residents will need to either pay for the vaccine or bill a back-up insurance such as Medicaid, if they have it. 

“For residents in a Medicare managed care plan, most plans will cover the cost of the RSV vaccine,” Dr. Gifford noted. “Billing arrangements for the MA plan for RSV should be the same as for other medications.”

Billing and other guidance for vaccines in long-trem care is available at https://www.ahcancal.org/Quality/Pages/GetVaccinated.aspx or at cms.gov.

This is an important topic and I thank Dr. Gifford for helping us understand the billing process better.

If there’s anything we’ve learned, it’s you want to get paid properly for work performed!

Sherrie Dornberger, RN, CDONA, FACDONA, is executive director of NADONA. Please send her your resident care-related questions at [email protected].