Reduce Vaccine Audit Risk Through Accurate Quantity Billed
To enhance profitability, pharmacy owners and operators have frequently incorporated immunization services into their offerings. While vaccines tend to carry a lower audit risk, the higher the cost of the vaccine, the more likely it is to be audited. The audit risk also increases when core billing elements of the vaccine claim are adjudicated incorrectly.
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NCPDP billing standards determine the billing quantity and unit of measure on claims so that all parties involved in the billing transaction are “speaking the same language”. This holds true for vaccines, such that each vaccine has a set quantity based on the NDC billed. Therefore, billing a quantity incongruent with the standard may trigger a third-party payor’s claim algorithm and result in an audit. Knowing the appropriate quantity and NCPDP billing unit for each vaccine the pharmacy bills, and how your pharmacy software system handles these quantities, is critical for billing vaccines correctly.
Listed in the chart below are many of the vaccines commonly billed by pharmacies, including their appropriate quantity and NCPDP billing unit. One factor that should immediately stand out is that many of these vaccines are billed with the NCPDP unit of “ML”, but most are less than 1 ML. If the pharmacy’s billing software is unable to handle/display decimals in the quantity field, the pharmacy must closely monitor these claims to ensure the vaccines are set up appropriately so the correct quantity is transmitting to third-party payors. The easiest way to confirm that the quantity is entered appropriately on the claim is to double check the cost of the vaccine on the claim. If the cost is double what you expect, it is possible the vaccine is not setup appropriately in the system. Take steps to correct the vaccine data elements before billing the claim to reduce audit risk.
| Type of Vaccine | Vaccine Name | Quantity & NCPDP Billing Unit | Considerations |
| Influenza | Fluzone® | 0.5 ML | Watch for yearly changes |
| Afluria® | 0.5 ML | ||
| Flucelvax® | 0.5 ML | ||
| FluLaval | 0.5 ML | ||
| Fluarix | 0.5 ML | ||
| Flublok® (egg-free) | 0.5 ML | ||
| Fluad® (65+) | 0.5 ML | ||
| Fluzone® High-Dose (65+) | 0.5 ML | ||
| FluMist® (nasal) | 1 EA | ||
| COVID-19 | Comirnaty® | 0.3 ML | Watch for yearly changes |
| SpikevaxTM | 0.5 ML | ||
| Novavax | 0.5 ML | ||
| Shingles | Shingrix | 1 EA | |
| Pneumococcal | Pneumococcal Conjugate Vaccines Vaxneuvance® (PCV15)Prevnar 20® (PCV20)CapvaxiveTM (PCV21) | 0.5 ML 0.5 ML 0.5 ML | |
| Pneumococcal Polysaccharide vaccine Pneumovax® 23 (PPSV23) | 0.5 ML | ||
| Tdap (Tetanus, Diphtheria, Pertussis) | Adacel® | 0.5 ML | |
| Boostrix | 0.5 ML | ||
| Hepatitis B | Engerix-B 10 mcg/0.5 ML 20 mcg/1 ML | 0.5 ML 1 ML | Aged 10 years and younger: 0.5 ML Aged 11 years and older: 1 ML |
| Recombivax HB® 5 mcg/0.5 ML 10 mcg/1 ML 40 mcg/1 ML (dialysis formulation) | 0.5 ML 1 ML 1 ML | Birth through 19 years: a series of 3 doses (5 mcg/0.5 ML each)Adolescents 11 through 15 years: either a series of 3 doses (5 mcg/0.5 ML each) or a series of 2 doses (10 mcg/1 ML each)Adults 20 years and older: a series of 3 doses (10 mcg/1 ML each)Pre-dialysis and dialysis patients: a series of 3 doses (40 mcg/1 ML each) | |
| Heplisav-BTM | 0.5 ML | ||
| Hepatitis A | Havrix 720 EL U/0.5 ML 1440 EL U/ML | 0.5 ML 1 ML | 12 months through 18 years: 720 EL U/0.5 ML19 years and older: 1440 EL U/ML |
| Vaqta® 25 unit/0.5 ML 50 unit/ML | 0.5 ML 1 ML | 12 months through 18 years: 25 unit/0.5 ML19 years and older: 50 unit/ML | |
| Hepatitis A + B | Twinrix | 1 ML | |
| HPV (Human Papillomavirus) | Gardasil® 9 | 0.5 ML | |
| MMR (Measles, Mumps, Rubella) | M-M-R® II | 1 EA | |
| Priorix | 1 EA | ||
| Meningococcal | Bexsero | 0.5 ML | |
| Trumenba® | 0.5 ML | ||
| Menveo | 0.5 ML | One-vial presentation (NDC 58160-827-03); pink cap | |
| 1 EA | Two-vial presentation (NDC 58160-955-09); gray cap + orange cap |
PAAS Tips:
- Billing a vaccine with an incorrect days’ supply is also known to trigger an audit. Vaccines are typically billed with a 1-day supply, unless instructed otherwise per adjudication messaging.
- Remove or block the NDC for seasonal vaccines that are no longer relevant (e.g., the influenza or COVID vaccine from the prior season)
- For more insight into billing vaccines, check out these other Newsline articles:
- Boost Your Bottom Line with In-Home Preventative Vaccine Administration (November 2024)
- Medicare and Vaccine Billing: What You Need to Know (October 2024)
- Flu Shot Season – Are You Prepared? (September 2024)
I enjoy assisting pharmacy staff both pre- and post-audit and enjoy providing them with knowledge and tools to decrease audit risk going forward. I write articles for Third-Party Newsline each month and answer member questions daily. I look forward to building professional relationships with each of our members and assisting you with your next audit.
