Wednesday 10 September 2014

Medicaid covered Immunizations and Federal Vaccine for Children (VFC) Program

Immunizations

Providers are encouraged to review valuable immunization information on the Department of Health and Human Services, Center for Disease Control and Preventions website, which provides recommended vaccines and schedules for children at http://www.cdc.gov/vaccines/.

Birth – 18 years:

Medicaid eligible members from birth through eighteen (18) years of age are eligible to receive free vaccines through the Federal Vaccine for Children (VFC) Program. SHP will reimburse the provider the administration fee for the vaccine as per their contract. Providers must bill using the appropriate assigned HCPCS procedure code to the vaccine and a modifier code, as indicated.

The provider must enroll with the VFC Program of the Department of Health to receive the vaccines free of charge and have sufficient supplies of the vaccines. Information regarding the VFC Program is available by contacting the State of Florida Department of Health, Bureau of Immunizations, at (800) 4-VFC-KID or (800) 483-2543, HSDI 4052 Bald Cypress Way, BIN A11, Tallahassee, Fl 32399-1719, or visit the website and click on immunization services: www.immunizeflorida.org/vfc.

For eligible members from birth through eighteen (18) years of age, the following vaccines and combination vaccines are available free to the enrolled VFC provider through Florida’s VFC Program:

* Diphtheria-Tetanus-acellular Pertussis (DTaP)
* Haemophilus influenzae type b (HIB)
* Hepatitis B (pediatric and adult)
* Human Papillomavirus (HPV)
* Influenza
* Meningococcal Conjugate (MCV4)
* Measles-Mumps-Rubella (MMR)
* Pneumococcal Conjugate (PCV7)
* Polio (IPV)
* Rotavirus
* Tetanus-Diphtheria (Td)
* Varicella

The following vaccines are available by request or for high-risk areas only through the VCF program:

Diphtheria and Tetanus (DT-Pediatric), Pneumococcal Polysaccharide (PPV), Hepatitis A and Meningococcal Polysaccharide (MPSV4).

CPT code 90460, 90471 - Immunization administration

CPT CODE and description

90460 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administere -average fee amount - $20 - $30

90461 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)

90471 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

90472 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

Policy Guidelines

If a significantly separately identifiable evaluation and management service is provided at the time of vaccine administration, the evaluation and management service should be reported in addition to the vaccine and toxoid procedure.

Separate reimbursement will be allowed for preventive medicine services 99381-99397.

Separate reimbursement will be allowed for the administration of the vaccines codes (90460-90474).

Immunization Guidelines

Applicable Codes: 90460-90749, G0008, G0009, G0010, Q2034-Q2039

Codes 90460 and 90461 must be reported in addition to the vaccine and toxoid codes 90476-90749.

Report codes 90460-90461 only when the physician or qualified health care professional provides faceto-face counseling of the patient and family during the administration of a vaccine. For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family for administration of vaccines to patients over 18 years of age, report codes 90471-90474.

Codes 90476-90748 identify the vaccine product only. To report the administration of a vaccine/toxoid, the vaccine product code must be used in addition to the administration code 90460-90474. Modifier 51 should not be reported for the vaccines/toxoids when performed with these administration procedures.

Each immunization given must be filed on a single line of the CMS 1500 claim form, with its specific CPT code.

The -25 modifier must be used with all evaluation and management services except preventive services CPT 99381-99397, when reporting a significant, separately identifiable service in addition to the immunization services.

It is inappropriate to use the unlisted vaccine code CPT 90749 to report immunization administration services.

The invoice from the laboratory or pharmacy the vaccine has been purchased from may be requested for claim review.

ZOSTAVAX® (Zoster Vaccine Live), has FDA approval for use in prevention of herpes zoster (shingles) in individuals 50 years of age and older.

Vaccines For Childern (VFC) Billing Instructions through 18 years of age: Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code. 

Lastly, in field 407-D7 (Product/Service ID), enter the Procedure Code. Providers may submit up to 4 claim lines with one transaction. For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age). 

For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.

* Vaccines for individuals under the age of 19 are provided free of charge by the VFC program. Medicaid WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the  VFC program. 

For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration.

* Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor often issues an executive order allowing pharmacies to immunize patients less than 19 years of age. 

Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85. By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.

Immunization CPT along with E & M codes

Previously announced as a revision to the Rebundling Policy and effective in the first quarter of 2014, UnitedHealthcare will deny Preventive Medicine Evaluation and Management (E/M) services (CPT codes 99381-99397) when reported on the same date of service as an immunization administration service (CPT codes 90460-90461 and 90471-90474) through the CCI Editing Policy. 

This change aligns with the CMS National Correct Coding Initiative (NCCI) and the American Medical Association Current Procedural Terminology (CPT®)

If modifier 25 is reported with the Preventive Medicine E/M service and the documentation supports that a significant and separately identifiable E/M service was provided on the same date as the administration service, both would be reimbursed. 

It would not be appropriate to additionally report the Preventive Medicine E/M code for the counseling provided when a vaccine is administered.

Medicaid billing Guide for Immunization Administration

Billing Instructions for 19 years of age and older: 

Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure code.  Lastly, in field 407-D7 (Product/Service ID), enter the Procedure code.  

Providers may submit up to 4 claim lines with one transaction.  For example, providers may submit one claim line with the Procedure code 90656 (Influenza Virus Vaccine), and another claim line for Procedure code 90471 (Immunization Administration through 19 years of age and older).  

For administration (ages 19 and older) of multiple vaccines on the same date, code 90471 should be used for the  first vaccine and 90472 for ANY other vaccines administered on that day. One line will be billed for 90472 indicating the additional number of vaccines administered (insert 1 or 2). 

Vaccines For Childern (VFC) Billing Instructions through 18 years of age:  

Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code.  

Lastly, in field 407-D7 (Product/Service ID), enter the Procedure Code.  Providers may submit up to 4 claim lines with one transaction.  For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age).  

For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.

** Vaccines for individuals under the age of 19 are provided free of charge by the VFC program. Medicaid WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the VFC program.  For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration. 

 ** Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor often issues an executive order allowing pharmacies to immunize patients less than 19 years of age.   

Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85.  By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.

If a clinical staff member performs vaccine administration with or without counseling under the supervision of the provider and, reports the service under the supervising provider, CPT codes 90471 , 90474 must be reported

Vaccine Administration Codes and Reimbursement Rates

The following codes should be used for all vaccine administration, including VFC vaccine administration for members 18 years old and younger. Report these codes in addition to the vaccine and toxoid code(s).

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