US · guidance

CMS Pub. 100-04, ch. 18, § 10.2.1.1

Claims Received with Missing Data

activein force · 2026-08-25 – presentas-observed

If a diagnosis code for a pneumococcus, hepatitis B, influenza virus, or COVID-19 vaccination is not reported

on a claim, contractors may enter the diagnosis on the claim and continue to process the claim for payment.

If the diagnosis code and the narrative description are correct, but the HCPCS code is incorrect, the MACs (Part

A or Part B) may correct the HCPCS code and pay the claim. For example, if the reported diagnosis code is Z23

and the narrative description (if annotated on the claim) says "flu shot" but the HCPCS code is incorrect,

contractors may change the HCPCS code and pay for the flu vaccine. Effective October 1, 2006, A/B MACs (B)

should follow the instructions in Pub. 100-04, Chapter 1, Section

• (MAC (Part B) Data Element Requirements) for claims submitted without a HCPCS code.

Claims for hepatitis B vaccinations must report the NPI number of the referring physician. In addition, if a

doctor of medicine or osteopathy does not order the influenza virus vaccine, the MACs (Part A) claims

require:

• The provider’s own NPI to be reported in the NPI field for the attending physician.

History

(Rev. 11355; Issued:04-14-22; Effective:05-16-22; Implementation:05-16-22)

Provenance

Source: cms.gov
Retrieved: 2026-08-25
Edition: iom-2026-08-25
Content hash: fb0bcd0023004cb245ce326109d08d48aab1c29278ce6f7683cb7f432f3b51c6

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