Immunizations are generally excluded from coverage under Medicare unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as antirabies treatment or tetanus antitoxin or booster vaccine. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such disease as smallpox, typhoid and polio, is not covered. In cases where a vaccination or inoculation is excluded from coverage, the entire charge will be denied (such as office visits, which were primarily for the purpose of administering a non-covered injection).


The vaccines listed below are eligible for payment. These vaccines may be reimbursed regardless of the setting in which they are furnished. In addition, the administration fee for these vaccines is also eligible for payment. Medicare provides specific coverage for influenza and pneumococcal vaccines for certain populations (see CMS National Coverage Determinations (NCDs) and other documentation); these vaccines are not addressed in this LCD; specific coverage information is available on the CMS and TrailBlazer Web sites.


Use the following codes to process the administration:


90471© – Immunization admin (For OPPS hospitals billing for the hepatitis B vaccine administration.) (For Comprehensive Outpatient Rehabilitation Facilities (CORFs) billing the influenza, pneumococcal and Hepatitis B vaccines.)
90472© – Immunization admin, each add (For OPPS hospitals billing for the hepatitis B vaccine administration.)
G0010 – Administration of hepatitis b vaccine (non-OPPS only.)
G0128 – Administration of the vaccines when provided by a registered nurse on 75X TOB (CORF.) (Part A only code)
Hepatitis B (90740, 90743, 90744, 90746, 90747) vaccine – For those who are at high or intermediate risk of contracting hepatitis B.
High-risk groups currently identified include:
    • End-Stage Renal Disease (ESRD) patients.
    • Hemophiliacs who receive Factor VIII or IX concentrates.
    • Clients of institutions for the mentally retarded.
    • People who live in the same household as a hepatitis B virus (HBV) carrier.
    • Homosexual men.
    • Illicit injectable drug abusers.
Intermediate risk groups currently identified include:
    • Staff in institutions for the mentally retarded.
    • Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work (V05.3).


Exception:
People in the above listed groups would not be considered at high or intermediate risk of contracting hepatitis B if there is laboratory evidence positive for antibodies to hepatitis B. (ESRD patients are routinely tested for hepatitis B antibodies as part of their continuing monitoring and therapy.)
The vaccine may be administered upon the order of a doctor of medicine or osteopathy by home health agencies, SNFs, ESRD facilities, hospital outpatient departments, people recognized under the “incident to” physicians’ services provision of law and doctors of medicine and osteopathy. A charge separate from the ESRD composite rate will be recognized and paid for administration of the vaccine to ESRD patients.
Tetanus (90703, 90714, 90718) – These injections are covered when given for an acute injury to a person who is incompletely immunized.
When a tetanus booster is given to a patient in the absence of an injury, the injection does not meet the coverage criteria for Medicare (even though it may be appropriate preventive treatment).
Rabies (90675) – Rabies is a disease that is carried by animals and transmitted by a bite or scratch.
When administering a rabies vaccine to a human who has had an encounter with an animal that is at high risk for rabies, bill procedure code 90675 and give the appropriate ICD-9-CM code for the exposure.
Limitations
In the absence of injury or direct exposure, preventative immunizations (vaccination or inoculation) against such diseases as small pox, polio, diphtheria, etc., are not covered. These include:
90476©
Adenovirus vaccine, type 4
90698©
Dtap-hib-ip vaccine, im
90477©
Adenovirus vaccine, type 7
90700©
Dtap vaccine, < 7yrs, 1m
90581©
Anthrax vaccine, sc
90701©
Dtp vaccine, < 7yrs, 1m
90585©
Bcg vaccine, precut
90702©
Dt vaccine, im
90586©
Bcg vaccine, intravesical
90704©
Mumps vaccine, sc
90632©
Hep a vaccine, adult im
90705©
Measles vaccine, sc
90633©
Hep a vacc, ped/adol, 2 dose
90706©
Rubella vaccine, sc
90634©
Hep a vacc, ped/adol, 3 dose
90707©
Mmr vaccine, sc
90636©
Hep a/hep b vacc, adult im
90708©
Measles-rubella vaccine, sc
90644©
Hib/men/tt vaccine, im
90710©
Mmrv vaccine, sc
90645©
Hib vaccine, hboc, im
90712©
Oral poliovirus vaccine
90646©
Hib vaccine, prp-d, im
90713©
Poliovirus, ipv, sc/im
90647©
Hib vaccine, prp-omp, im
90715©
Tdap vaccine >7 im
90648©
Hib vaccine, prp-t, im
90716©
Chicken pox vaccine, sc
90649©
hpv vaccine 4 valent, im
90717©
Yellow fever vaccine, sc
90650©
hpv vaccine 2 valent, im
90719©
Diphtheria vaccine, im
Influenza virus vaccine
90720©
Dtp/hib vaccine, im
90660©*
Flu vaccine, nasal
90721©
Dtap/hib vaccine, im
90663©
Flu vacc pandemic h1n1
90723©
Dtap-hep b-ipv vaccine, im
90664©
Flu vacc pandemic intranasal
90725©
Cholera vaccine, injectable
90665©
Lyme disease vaccine, im
90727©
Plague vaccine, im
90666©
Flu vac pandem prsrv free im
90733©
Meningococcal vaccine, sc
90667©
Flu vac pandemic adjuvant im
90734©
Meningococcal vaccine, im
90668©
Flu vac pandemic splt im
90735©
Encephalitis vaccine, sc
90669©*
Pneumococcal vacc, 7 val im
90736©
Zoster vacc, sc
90670©
Pneumococcal vacc, 13 val im
Rabies vaccine, id
90680©
Rotovirus vaccine, 3 dose, oral
90681©
Rotavirus vacc 2 dose oral
90690©
Typhoid vaccine, oral
90691©
Typhoid vaccine, im
90692©
Typhoid vaccine, h-p, sc/id
90693©
Typhoid vaccine, akd, sc
90696©
Dtap-ipv vacc 4-6 yr im
In cases where a vaccination or inoculation is excluded from coverage, the entire charge will be denied (such as office visits, which were primarily for the purpose of administering a non-covered injection).
*Note: Coverage of 90660© (flu vaccine, nasal) is expanded for individuals ages 5 through 49 (previously non-covered). See CMS NCDs related to Flu vaccines for additional details.
*Note: Coverage of 90669© (pneumococcal vacc, 7 val im) is expanded for individuals younger than 5 years (previously non-covered). See CMS Change Request (CR) 5910 for additional details.


Billing For a Single Administration 


Providers should bill the appropriate Procedure  immunization administration code(s) 90465, 90467, 90471, or 90473 (Immunization administration…first injection/first administration/one vaccine) when administering one immunization. The next line on the claim form must contain the specific Procedure  code for the vaccine, with $0.00 in the “billed charges” column (see pg. 102 for an
example). 




• Do not report Procedure  codes 90465 and 90467 on the same date of service 


• Do not report Procedure  codes 90471 and 90473 on the same date of service


2007 Louisiana Medicaid Professional Services Provider Training 98


Billing for Multiple Administrations


When administering more than one immunization, providers should bill as described above for a single administration. The appropriate procedure code(s) 90466, 90468, 90472, and 90474 (Immunization administration…each additional injection/administration/vaccine) should then be listed with the appropriate number of units for the additional vaccines placed in the “units” column. The specific vaccines should then be listed on subsequent lines. The number of specific vaccines listed after Procedure  administration codes should match the number of units listed in the units column. Examples of this scenario are on pages 103 through 107.


• Use Procedure  codes 90466 and/or 90468 with 90465 OR 90467 to report more than one vaccine administered. Do NOT use 90466 and/or 90468 with 90471 or 90473.


• Use Procedure  codes 90472 and/or 90474 with 90471 OR 90473 to report more than one vaccine administered. Do NOT use 90472 and/or 90474 with 90465 or 90467. 


Hard Copy Claim Filing for Greater Than Four Administrations



When billing hard copy claims for more than four immunizations and the six-line claim form limit is exceeded, providers should bill on two CMS-1500 claim forms. The first claim should follow the instructions above for billing the single administration. A second CMS-1500 claim form should be used to bill the remaining immunizations as described above for billing multiple administrations. An example is shown on pages 104 and 105.

Drug Wastage
Medicare provides payment for the discarded drug/biological remaining in a single-use drug product after administering what is reasonable and necessary for the patient’s condition. If the physician has made good faith efforts to minimize the unused portion of the drug/biological in how patients are scheduled and how he ordered, accepted, stored, used the drug, and made good faith efforts to minimize the unused portion of the drug in how it is supplied, then the program will cover the amount of drug discarded along with the amount administered Documentation requirements are given below. Coding and billing instructions can be referenced in the attached article. Refer to national policy:Medicare Claims Processing Manual – Pub. 100-04, Chapter 17, Section 40.
Note: The JW modifier is not used on claims for drugs or biologicals provided under the Competitive Acquisition Program (CAP). Reference to national policy: Medicare Claims Processing Manual, Pub. 100-04, Chapter 17, Section 100.2.9.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 22X, 23X, 71X, 72X, 73X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified Bill Type and Revenue Codes applicable for use with CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
0550, 0559, 0636, 0771
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
90675©
Rabies vaccine, im
90703©
Tetanus vaccine, im
90714©
Td vaccine no prsrv >/= 7 im
90718©
Td vaccine > 7, im
90740©
Hep b vacc, ill pat 3 dose im
90743©
Hep b vacc, adol, 2 dose, im
90744©
Hep b vaccine, ped/adol, im
90746©
Hep b vaccine, adult, im
90747©
Hep b vaccine, ill pat, im
G0010
Administration of hepatitis b vaccine
G0128
Administration of the vaccines when provided by a registered nurse on 75X TOB (CORF)(Part A only)
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as preventive services.
Medicare is establishing the following limited coverage for hepatitis B (CPT/HCPCS codes 90740, 90743, 90744, 90746, 90747 and G0010):
Covered for:
286.0–286.1
Coagulation defects
302.0
Ego-dystonic sexual orientation
304.00–304.03
Opioid type dependence
304.10–304.13
Sedative, hypnotic or anxiolytic dependence
304.20–304.23
Cocaine dependence
304.30–304.33
Cannabis dependence
304.40–304.43
Amphetamine and other psychostimulant dependence
304.50–304.53
Hallucinogen dependence
304.60–304.63
Other specified drug dependence
304.70–304.73
Combinations of opioid type drug with any other
304.80–304.83
Combinations of drug dependence excluding opioid type drug
304.90–304.93
Unspecified drug dependence
305.90–305.93
Nondependent abuse of drugs
318.1–318.2
Other specified mental retardation
319
Unspecified mental retardation
585.1–585.6
Chronic kidney disease (CKD)
585.9
Chronic kidney disease, unspecified
758.0
Down’s syndrome
V05.3
Need for viral hepatitis prophylactic vaccination and inoculation against single disease
Medicare is establishing the following limited coverage for tetanus (CPT/HCPCS codes 90703, 90714 and 90718):
Covered for:
870.0–870.4
Open wound of ocular adnexa
870.8–870.9
Open wound of ocular adnexa
871.0–871.7
Open wound of eyeball
871.9
Unspecified open wound of eyeball
872.00–872.02
Open wound, external ear without mention of complication
872.10–872.12
Open wound, external ear, complicated
872.61–872.64
Open wound, other specified parts of ear, without mention of complication
872.69
Open wound, other and multiple sites of ear, without mention of complication
872.71–872.74
Open wound, other specified parts of ear, complicated
872.79
Open wound, other and multiple sites of ear, complicated
872.8–872.9
Open wound of ear
873.0–873.1
Other open wound of head
873.20–873.22
Open wound of nose, without mention of complication
873.29
Open wound of multiple sites of nose, without mention of complication
873.30–873.33
Open wound of nose, complicated
873.39
Open wound of multiple sites of nose, complicated
873.40–873.44
Open wound of face, without mention of complication
873.49
Open wound of other and multiple sites of face, without mention of complication
873.50–873.54
Open wound of face, complicated
873.59
Open wound of other and multiple sites of face, complicated
873.60–873.65
Open wound of internal structures of mouth, without mention of complication
873.69
Open wound of other and multiple sites of internal structures of mouth, without mention of complication
873.70–873.75
Open wound of internal structures of mouth, complicated
873.79
Open wound of other and multiple sites of internal structures of mouth, complicated
873.8–873.9
Other open wound of head
874.00–874.02
Open wound of larynx and trachea, without mention of complication
874.10–874.12
Open wound of larynx and trachea, complicated
874.2–874.5
Open wound of neck
874.8–874.9
Open wound of neck
875.0–875.1
Open wound of chest (wall)
876.0–876.1
Open wound of back
877.0–877.1
Open wound of buttock
878.0–878.9
Open wound of genital organs (external), including traumatic amputation
879.0–879.9
Open wound of other and unspecified sites, except limbs
880.00–880.03
Open wound of shoulder and upper arm, without mention of complication
880.09
Open wound of multiple sites of shoulder and upper arm, without mention of complication
880.10–880.13
Open wound of shoulder and upper arm, complicated
880.19
Open wound of multiple sites of shoulder and upper arm, complicated
880.20–880.23
Open wound of shoulder and upper arm, with tendon involvement
880.29
Open wound of multiple sites of shoulder and upper arm, with tendon involvement
881.00–881.02
Open wound of elbow, forearm and wrist, without mention of complication
881.10–881.12
Open wound of elbow, forearm and wrist, complicated
881.20–881.22
Open wound of elbow, forearm and wrist, with tendon involvement
882.0–882.2
Open wound of hand except finger(s) alone
883.0–883.2
Open wound of finger(s)
884.0–884.2
Multiple and unspecified open wound of upper limb
885.0–885.1
Traumatic amputation of thumb (complete) (partial)
886.0–886.1
Traumatic amputation of other finger(s) (complete) (partial)
887.0–887.7
Traumatic amputation of arm and hand (complete) (partial)
890.0–890.2
Open wound of hip and thigh
891.0–891.2
Open wound of knee, leg (except thigh) and ankle
892.0–892.2
Open wound of foot except toe(s) alone
893.0–893.2
Open wound of toe(s)
894.0–894.2
Multiple and unspecified open wound of lower limb
895.0–895.1
Traumatic amputation of toe(s) (complete) (partial)
896.0–896.3
Traumatic amputation of foot (complete) (partial)
897.0–897.7
Traumatic amputation of leg(s) (complete) (partial)
910.6–910.9
Superficial injury of face, neck, and scalp except eye
911.6–911.9
Superficial injury of trunk
912.6–912.9
Superficial injury of shoulder and upper arm
913.6–913.9
Superficial injury of elbow, forearm, and wrist
914.6–914.9
Superficial injury of hand(s) except finger(s) alone
915.6–915.9
Superficial injury of finger(s)
916.6–916.9
Superficial injury of hip, thigh, leg, and ankle
917.6–917.9
Superficial injury of foot and toes
918.9
Other and unspecified superficial injuries of eye
919.6–919.9
Superficial injury of other, multiple, and unspecified site
959.01
Head injury, unspecified
959.09
Injury of face and neck
959.11–959.14
Injury, trunk
959.19
Injury, other sites of trunk
959.2–959.9
Injury, other and unspecified
Medicare is establishing the following limited coverage for rabies (CPT/HCPCS code 90675):
Covered for:
872.00–872.02
Open wound, external ear without mention of complication
872.10–872.12
Open wound, external ear, complicated
872.79
Open wound of ear, other and multiple sites, complicated
872.8–872.9
Open wound of ear, part unspecified
873.0–873.1
Open wound of scalp
873.20
Open wound of nose, unspecified site, without mention of complication
873.29
Open wound of nose, multiple sites, without mention of complication
873.30
Open wound of nose, unspecified site, complicated
873.39
Open wound of nose, multiple sites, complicated
873.40–873.44
Open wound of face, without mention of complication
873.49
Open wound of other and multiple sites of face, without mention of complication
873.50–873.54
Open wound of face, complicated
873.59
Open wound of other and multiple sites of face, complicated
873.60
Open wound of mouth, unspecified site, without mention of complication
873.69
Open wound of other and multiple sites of mouth, without mention of complication
873.70
Open wound of mouth, unspecified site, complicated
873.79
Open wound of other and multiple sites of mouth, complicated
873.8–873.9
Other and unspecified open wound of head
874.8–874.9
Open wound of neck, other and unspecified parts
875.0–875.1
Open wound of chest (wall)
876.0–876.1
Open wound of back
877.0–877.1
Open wound of buttocks
878.0–878.9
Open wound of genital organs (external), including traumatic amputation
879.0–879.9
Open wound of other and unspecified sites, except limbs
880.00–880.03
Open wound of shoulder and upper arm, without mention of complication
880.09
Open wound of multiple sites of shoulder and upper arm, without mention of complication
880.10–880.13
Open wound of shoulder and upper arm, complicated
880.19
Open wound of multiple sites of shoulder and upper arm, complicated
880.20–880.23
Open wound of shoulder and upper arm, with tendon involvement
880.29
Open wound of multiple sites of shoulder and upper arm, with tendon involvement
881.00–881.02
Open wound of elbow, forearm and wrist, without mention of complication
881.10–881.12
Open wound of elbow, forearm and wrist, complicated
881.20–881.22
Open wound of elbow, forearm and wrist, with tendon involvement
882.0–882.2
Open wound of hand except finger(s) alone
883.0–883.2
Open wound of finger(s)
884.0–884.2
Multiple and unspecified open wound of upper limb
885.0–885.1
Traumatic amputation of thumb (complete) (partial)
886.0–886.1
Traumatic amputation of other finger(s) (complete) (partial)
887.0–887.7
Traumatic amputation of arm and hand (complete) (partial)
890.0–890.2
Open wound of hip and thigh
891.0–891.2
Open wound of knee, leg (except thigh) and ankle
892.0–892.2
Open wound of foot except toe(s) alone
893.0–893.2
Open wound of toe(s)
894.0–894.2
Multiple and unspecified open wound of lower limb
895.0–895.1
Traumatic amputation of toe(s) (complete) (partial)
896.0–896.3
Traumatic amputation of foot (complete) (partial)
897.0–897.7
Traumatic amputation of leg(s) (complete) (partial)
910.8–910.9
Other and unspecified superficial injury of face, neck and scalp
911.8–911.9
Other and unspecified superficial injury of trunk
912.8–912.9
Other and unspecified superficial injury of shoulder and upper arm
913.8–913.9
Other and unspecified superficial injury of elbow, forearm, and wrist
914.8–914.9
Other and unspecified superficial injury of hand(s) except finger(s) alone
915.8–915.9
Other and unspecified superficial injury of finger(s)
916.8–916.9
Other and unspecified superficial injury of hip, thigh, leg, and ankle
917.8–917.9
Other and unspecified superficial injury of foot and toes
919.8–919.9
Other and unspecified superficial injury of other, multiple, and unspecified site
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Claims for hepatitis B vaccinations must include the identification number of the referring physician.
Drug Wastage Documentation Requirements
Any amount wasted must be clearly documented in the medical record, regardless of whether the JW modifier will be used in billing for the drug/biological, with:
  • Date and time.
  • Amount of medication wasted.
  • Reason for the wastage.
Appendices
N/A
Utilization Guidelines
In accordance with CMS ruling 95-1(V), utilization of the service(s) should be consistent with locally acceptable standards of practice.
Compliance with the provisions in this LCD may be monitored and addressed through postpayment data analysis and subsequent medical review audits.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Consolidation
TrailBlazer adopted, unchanged, the TrailBlazer LCD, “Immunizations”, for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of the sources of information is found with original contractor LCD.