CMS Pub. 100-02, ch. 13, § 220.1

Influenza (G0008), Pneumococcal (G0009), and COVID-19 (90480) Vaccines, and

Certain COVID-19 Monoclonal Antibody Products

Prior to July 1, 2025, influenza, pneumococcal, COVID-19 vaccines, and their

administration were not paid at the time of service and were paid at 100 percent of

reasonable cost through the cost report.

Effective for dates of service on or after July 1, 2025, RHCs shall report all Part B

preventive vaccines and their administration – pneumococcal, influenza, and COVID-19

on the claim at the time of service. A visit/encounter is not required for these services;

however, if reported on the same day, the vaccines and administrations shall receive a

separate payment. Coinsurance and deductible do not apply to these vaccines or their

administration.

Although paid at the time of service, payments for these services must be annually

reconciled with the RHC’s actual vaccine and vaccine administration costs, to ensure

these services are ultimately reimbursed at 100% of reasonable costs through the cost

report.

Each year, CMS updates the Seasonal Influenza Vaccines Pricing webpage:

https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/vaccine-pricing

to reflect the seasonal influenza virus vaccines and their applicable payment allowances

that are effective August 1 through July 31 of the following year. RHCs must refer to this

webpage to ensure they are billing the appropriate HCPCS codes for the applicable

influenza season.

Note: An additional payment for influenza, pneumococcal, COVID-19 vaccine

administration in the home can be made, provided that a home visit meets all the

requirements of both part 405, subpart X, for RHC services provided in the home, and §

410.152(h)(3)(iii) for the in-home additional payment for Part B preventive vaccine

administration. See Pub. 100-02, Chapter 15, Section 50.4.4.2.E.

Covered monoclonal antibody products used as pre-exposure prophylaxis prevention of

COVID-19 and their administration are paid at 100 percent of reasonable cost through the

cost report. Monoclonal antibody products used for the treatment or for post-exposure

prophylaxis of COVID-19 (when they are not purchased by the government) and their

administration are paid through the cost report until the end of the calendar year in which

the Emergency Use Authorization declaration for drugs and biological products with

respect to COVID-19 ends.

Hepatitis B Vaccine (G0010)

Prior to January 1, 2025, hepatitis B vaccine and its administration was included in the

RHC visit and was not separately billable. The cost of the vaccine and its administration

could be included in the line item for the otherwise qualifying visit. A visit could not be

billed if vaccine administration was the only service the RHC provides. The beneficiary

coinsurance and deductible were waived.

Effective January 1, 2025, payment for the hepatitis B vaccine and its administration is

through the cost report and no longer included in the RHC AIR.

Effective for dates of service on or after July 1, 2025, RHCs shall report all Part B

preventive vaccines and their administration – including hepatitis B on the claim at the

time of service. A visit/encounter is not required for these services; however, if a visit

occurs on the same day, the vaccines and administrations shall receive a separate

payment. Coinsurance and deductible do not apply to these vaccines or their

administration.

Note: An additional payment for hepatitis B vaccine administration in the home can be

made, provided that a home visit meets all the requirements of both part 405, subpart X,

for RHC services provided in the home, and § 410.152(h)(3)(iii) for the in-home

additional payment for Part B preventive vaccine administration. See Pub. 100-02,

Chapter 15, Section 50.4.4.2.E for more information.

Although paid at the time of service, payments for these services must be annually

reconciled with the RHC’s actual vaccine and vaccine administration costs, to ensure

these services are ultimately reimbursed at 100% of reasonable costs through the cost

report.

Initial Preventive Physical Exam (G0402)

The IPPE is a face-to-face one-time exam that must occur within the first 12 months

following the beneficiary’s enrollment. The IPPE can be billed as a stand-alone visit if it

is the only medical service provided on that day with an RHC practitioner. If an IPPE

visit is furnished on the same day as another billable visit, two visits may be billed. The

beneficiary coinsurance and deductible are waived.

Annual Wellness Visit (G0438 and G0439)

The AWV is a face-to-face personalized prevention visit for beneficiaries who are not

within the first 12 months of their first Part B coverage period and have not received an

IPPE or AWV within the past 12 months. Advance Care Planning (ACP) and

administration of a standardized, evidence-based assessment of physical activity and

nutrition can be furnished as a part of the AWV. The AWV can be billed as a stand-alone

visit if it is the only medical service provided on that day with an RHC practitioner. If the

AWV is furnished on the same day as another medical visit, it is not a separately billable

visit. The beneficiary coinsurance and deductible are waived.

More information regarding ACP and an evidence-based assessment of physical activity

and nutrition as an optional AWV element is available on the CMS website:

https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-

visits/annual-wellness-visit

Diabetes Self-Management Training (G0108) and Medical Nutrition Therapy (97802

and 97803)

Diabetes self-management training or medical nutrition therapy provided by a registered

dietician or nutritional professional at an RHC may be considered incident to a visit with

an RHC practitioner provided all applicable conditions are met. DSMT and MNT are not

billable visits in an RHC, although the cost may be allowable on the cost report. RHCs

cannot bill a visit for services furnished by registered dieticians or nutritional

professionals. However, RHCs are permitted to become certified providers of DSMT

services and report the cost of such services on their cost report for inclusion in the

computation of their AIR. The beneficiary coinsurance and deductible apply.

Screening Pelvic and Clinical Breast Examination (G0101)

Screening pelvic and clinical breast examination can be billed as a stand-alone visit if it is

the only medical service provided on that day with an RHC practitioner. If it is furnished

on the same day as another medical visit, it is not a separately billable visit. The

beneficiary coinsurance and deductible are waived.

Screening Papanicolaou Smear (Q0091)

Screening Papanicolaou smear can be billed as a stand-alone visit if it is the only medical

service provided on that day with an RHC practitioner. If it is furnished on the same day

as another medical visit, it is not a separately billable visit. The beneficiary coinsurance

and deductible are waived.

Prostate Cancer Screening (G0102)

Prostate cancer screening can be billed as a stand-alone visit if it is the only medical

service provided on that day with an RHC practitioner. If it is furnished on the same day

as another medical visit, it is not a separately billable visit. The beneficiary coinsurance

and deductible apply.

Glaucoma Screening (G0117 and G0118)

Glaucoma screening for high risk patients can be billed as a stand-alone visit if it is the

only medical service provided on that day with an RHC practitioner. If it is furnished on

the same day as another medical visit, it is not a separately billable visit. The beneficiary

coinsurance and deductible apply.

Lung Cancer Screening Using Low Dose Computed Tomography (LDCT) (G0296)

LDCT can be billed as a stand-alone visit if it is the only medical service provided on that

day with an RHC practitioner. If it is furnished on the same day as another medical visit,

it is not a separately billable visit. The beneficiary coinsurance and deductible are

waived.

Drugs Covered as Additional Preventive Services (DCAPS) DCAPS drugs, and any

supply and administration fee, are paid at 100 percent of the Medicare payment amount.

The Medicare payment amount for DCAPS drugs, and any supply and administration fee,

is described in the Medicare Claims Processing Manual (100-04), Chapter 18, Section

250. The beneficiary coinsurance and deductible are waived.

These services are separately billable and are paid on a claim-by-claim basis. Therefore,

they do not affect any other claims billed on the same day.

Coding for DCAPS drugs and related supply and administration fees is listed on the CMS

webpage:

• The coding and other guidance for Part B coverage and payment of PrEP for HIV is

located at https://www.cms.gov/medicare/coverage/prep. The HCPCS code for the

injection of PrEP for HIV is G0012.

NOTE: Hepatitis C Screening (G0472) is a technical service only and therefore it is not

paid as part of the RHC visit.