New CMS Payment Rates for 2025–2026 Flu Season: What Providers Need to Know

On August 13, 2025, the Centers for Medicare & Medicaid Services (CMS) released the updated Medicare Part B payment allowance limits for the 2025–2026 influenza (flu) season. These rates are effective August 1, 2025, through July 31, 2026 and reflect important changes that providers need to account for in their billing processes. The updates include rate increases for several vaccines and one new vaccine code, ensuring that payments align with inflation and the evolving cost of vaccine production.

Key Flu Vaccines Recommended for 2025–2026

CMS recommends the following three vaccines for Medicare beneficiaries at higher risk of flu-related complications:

• Fluzone High-Dose (Trivalent, Inactivated)
• Flublok (Trivalent, Recombinant)
• Fluad (Trivalent, Adjuvanted, Inactivated)

If these vaccines are unavailable, providers are encouraged to administer a standard-dose trivalent flu vaccine.

Flu Vaccine Codes and Payment Allowances

Below are the CPT® codes and Medicare payment rates for flu vaccines for the 2025–2026 season:

Source: CMS 

How Medicare Calculates Vaccine Payments

Under Medicare Part B, payments for flu vaccines are generally set at 95% of the average wholesale price (AWP). However, in certain care settings—such as hospital outpatient departments, rural health clinics (RHCs), and federally qualified health centers (FQHCs)—payment is based on reasonable cost rather than AWP. Additionally, CMS applies geographic adjustments to reflect cost variations across different regions.

Billing Requirements for Flu Vaccines

To ensure proper reimbursement, providers must:

1. Bill the administration fee:

• CPT® 90471 – Administration code for commercial payers
• HCPCS Level II G0008 – Administration code for Medicare claims

2. Include the appropriate ICD-10-CM diagnosis code:

• Z23: Encounter for immunization

3. Note the seasonal coverage period:

• Medicare covers one flu shot per season (August 1–July 31), not per calendar year.
• This means a patient could receive two flu shots in a single calendar year if they receive one in early 2025 and another later in 2025 for the next season, and both will be covered.

Importantly, Medicare Part B beneficiaries do not incur copayments, coinsurance, or deductibles for covered seasonal flu shots.

Enhanced Medicare Payments for In-Home Flu Vaccinations

In recognition of the challenges faced by homebound patients, CMS provides an additional payment of approximately $40 per vaccine administration when performed inside a patient’s home, effective since January 1, 2024.

To qualify for the in-home administration payment:

The patient must have a documented medical reason or legitimate barrier to leaving their home.

Providers must document the reason in the medical record and include appropriate ICD-10-CM coding.

The additional payment:

• Cannot be billed for residents in Medicare- or Medicaid-certified nursing facilities.
• Is limited to one payment per patient per date of service.
• Allows a maximum of five vaccine administration services per day for fewer than 10 Medicare patients vaccinated at the same group home.
• If 10 or more patients are vaccinated at the same group living facility on the same day, only one additional payment applies.
• Does not apply when the visit is primarily for another billable service, such as an E/M visit.

For this additional payment, bill HCPCS Level II code M0201:

• Administration of pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccine inside a patient’s home; report once per home per date of service.

This supplemental payment also applies to other vaccines like COVID-19, hepatitis B, and pneumococcal vaccines.

Why These CMS Updates Matter for Providers

Accurate billing for flu vaccines is critical for revenue cycle management and compliance. The annual CMS updates ensure providers receive fair reimbursement while promoting access to vaccines for Medicare beneficiaries. Providers should:

• Update their billing systems and EHRs with the latest CPT/HCPCS codes and payment rates.
• Train billing and coding staff on new payment policies and documentation requirements.
• Monitor claims denials related to flu vaccinations, as most errors stem from missing administration codes or improper ICD-10-CM coding.

Best Practices for Maximizing Reimbursement

• Stay current with CMS seasonal updates – including payment rates, codes, and coverage rules.
• Document homebound status clearly for patients receiving in-home vaccinations.
• Perform regular internal audits to ensure coding accuracy and compliance with Medicare rules.
• Leverage automated eligibility verification to confirm Medicare Part B coverage for vaccinations.

Final Takeaway

CMS’s updated payment rates and billing guidance for the 2025–2026 flu season are more than just administrative details—they’re an opportunity for providers to ensure proper reimbursement and increase access to preventive care for vulnerable populations.

Struggling to Keep Up with CMS Vaccine Billing Updates? Partner with an Expert

Each year, CMS updates payment allowances, codes, and billing rules for flu and other vaccines—and even small errors can result in claim denials, delayed reimbursements, or compliance risks. Managing these details in-house can overwhelm staff who are already balancing patient care with administrative duties.

That’s where our expert medical billing and medical coding services come in. At Bristol Healthcare Services, we specialize in helping practices stay ahead of CMS changes, ensuring claims are submitted correctly the first time. Our certified coders and billing professionals:

• Stay up to date on the latest CMS updates and code changes
• Ensure accurate claim submission with the right CPT®, HCPCS, and ICD-10-CM codes
• Maximize reimbursements by reducing claim denials and delays
• Free up your staff’s time so they can focus on patient care

With our expertise, you’ll never have to worry about missing a code update or misbilling a vaccine again.

Ready to simplify your billing process and boost reimbursement? Contact us today to learn how our customized revenue cycle management solutions can help your practice.