CPT code 90460, 90471 - VFC 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).

Vaccines for Children (VFC)

VFC is covered under Section 1928 of the Social Security Act. Implemented on October 1, 1994, it was an “unprecedented approach to improving vaccine availability nationwide by providing vaccines free of charge to VFC-eligible children through public and private providers.”

The goal of VFC is to ensure that no VFC-eligible child contracts a vaccine preventable disease because of his/her parent’s inability to pay for the vaccine or its administration.


Persons eligible for VFC vaccines are between the ages of birth through 18 who meet the following criteria:

* *  Eligible for Medicaid

* *  No insurance

* *  Have health insurance, but it does not offer immunization coverage and they receive their immunizations through a Federally Qualified Health Center

* *  Native American or Alaska native

Providers can obtain an enrollment packet by contacting the Office of Public Health’s (OPH) Immunization Section at (504) 838-5300.

Guidelines for Reporting Immunization Administration

Codes 90460 and 90461 or 90471–90474 are reported in addition to vaccine/toxoid code(s) 90476– 90749.

• Codes 90460 and 90461 do not differentiate by routes of administration or "first" versus "each additional" administration.

• The age designation for codes 90460 and 90461 (ie, through age 18) is consistent with the age requirements under the federal Vaccines for Children (VFC) program.

• When the physician or qualified health care professional (eg, nonphysicians if allowed under state scope of practice) provides face-to-face counseling for the patient and family during the administration of a vaccine to a patient aged 18 years or younger, code 90460 or a combination of codes 90460 and 90461 are reported. The medical record documentation must support that the physician or other qualified health care professional provided the vaccine counseling.

• Code 90460 is reported for the first component of each vaccine administered whether it is a single or combination vaccine.

• Code 90461 is reported in conjunction with 90460 for each additional component in a given vaccine. The word "component" refers to each antigen in a vaccine that prevents disease(s) caused by one organism. Combination vaccines are those vaccines that contain multiple vaccine components (antigens).

• The immunization administration codes include the provider (ie, physician or other qualified health care professional) work of discussing risks and benefits of the vaccines, providing parents with a copy of the Centers for Disease Control and Prevention (CDC) Vaccine Information Statement (VIS) for each component, the cost of the nursing time to record each component administered in the medical record and statewide vaccine registry, giving the vaccine, observing and addressing reactions or side effects, and the cost of supplies (eg, syringe, needle, bandages).

• When the physician or qualified health care professional does not perform the vaccine counseling to the patient or family, or when vaccines are administered to patients older than 18 years, codes 90471– 90474 are reported instead of codes 90460–90461. Codes 90471–90474 are reported as appropriate based on their current guidelines (ie, either 90471 or 90473 is reported for the first vaccine administered to a patient on a calendar date, and codes 90472 and 90474 are reported for each additional vaccine given on the same date based on its route of administration). Coding Vaccine/Toxoid Products

CPT codes 90476–90749 are used to report vaccine/toxoid products. They are always reported separately from immunization administration codes (90460–90461, 90471–90474). Each specific vaccine product administered must be reported to meet the requirements of immunization registries, vaccine distribution programs, and reporting systems (eg, Vaccine Adverse Event Reporting System).

Each vaccine/toxoid product code is specific to the product manufacturer and brand, chemical formulation, specific schedule (number of doses or timing), dosage, appropriate age guidelines, and route of administration. Close attention must be paid to the specific product code and descriptor to ensure that the correct code is reported. For example, there are 8 codes available for reporting the influenza virus vaccine (90655–90663). Each product is different, and the differences can be subtle.

It would be incorrect, for example, to report 90655 (influenza virus vaccine, split virus, preservative free, for children 6–35 months of age, for intramuscular use) when administering influenza virus vaccine, split virus, 6 to 35 months' dosage, for intramuscular use (code 90657).

When a combination vaccine is administered, its specific code should be reported. Never report each component of a combination vaccine separately unless the components are administered and the combination vaccine is not administered. Typically the only times components are reported rather than combination vaccines is when the physician elects to administer the component vaccines because of nonavailability of the combination vaccine, or there is clinical reason for administering each component separately.

Modifier 51 (multiple procedures) should not be reported with vaccines/toxoids or immunization administration codes.

To avoid vaccine coding errors, a practice's encounter form would ideally only include the specific codes for the vaccines that are administered by the practice. It is neither necessary nor desirable to include every product code on the practice superbill.

V67.59 as primary, educate it by providing a copy of the ICD-9-CM guidelines. If the payer continues to refuse to follow the guidelines, get its policy in writing. Code 90471 is reported because the physician or other qualified health care professional did not perform the vaccine counseling. If state scope of practice includes nurses within the definition of "other qualified health care professionals," code 90460 would be reported instead of 90471.

7. A 4-year-old is seen for her preventive medicine visit. She is given her second dose of the measles, mumps, rubella, and varicella (MMRV) vaccine and her fourth dose of the DTaP-IPV vaccine. Although the physician personally performed the counseling for both vaccines, the medical record only supports face-to-face counseling for the MMRV vaccine.


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.



Immunization Administration Codes 90460 and 90461

Effective May 23, 2011, a daily maximum limit of nine units for CPT code 90460 and five units for 90461 will be assigned. A duplicate procedure edit will apply to charges submitted for CPT code 90460 exceeding nine units and 90461 exceeding five units per date of service. Effective February 20, 2012, the daily maximum limit for CPT Code 90461 will increase to seven. The daily maximum limit for CPT Code 90460 will remain at nine units.  Respiratory Treatment Demonstration or evaluation of patient use of an aerosol generator, nebulizer, metered dose inhaler, or IPPB devise (CPT code 94664) is considered mutually exclusive to an office visit.

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).

CPT Code          Description                Rate

Use the following codes for vaccine administration to patients of any age when the administration is not accompanied by any face-to-face counseling, or for administration to patients over 18 with or without counseling:

90471 (Including percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccines/toxoid) (do not report in conjunction with 90473) $21.68


+ 90472 Each additional vaccine/toxoid (List separately in addition to 90471, 90473) $12.59


90473 By intranasal or oral route; one vaccine (single or combination vaccine/toxoid) (do not report in conjunction with 90471)  $21.68


+ 90474 Each additional vaccine/toxoid administered by intranasal or oral route (List separately in addition to 90471, 90473) $12.59

Using Vaccine Administration Codes 90471-90474

The immunization administration codes 90471-90474 need to be billed as one (1) line item, and the vaccine product should be billed as a separate line item. In order for an immunization claim to be reimbursed both an administration code and the vaccine product must be billed. If an immunization is the only service rendered, providers may not submit charges for an E&M service.

Adult immunizations are reimbursed at the lower of: billed charges, or the Medicaid fee schedule amount  for each immunization.

Note: Providers are not to bill CPT codes 90471-90474 for children ages 0-18 for whom counseling was given (see section “Using Pediatric Immunization Codes 90460 and 90461” in this manual). CPT Codes 90471-90474 must only be billed for members (ages 19 and older) or members ages 18 and under for whom no counseling was given.

1. Patient/Parent are not counseled on 2 multi-component vaccines. Both are injectables. Patient is 5 years old.

90471 and 90472

Teaching point: Even though the patient meets the age requirement, counseling is not done.


2. Patient/Parent are counseled by the nurse on 2 multiple component vaccines. Both are injectables. Patient is 5 years old.


90471 and 90472

Teaching point: Even though the patient meets the age requirement, vaccine is done by clinical staff (nurse) and therefore
does not meet the OQHCP requirement.


Vaccine Administration Billing Instructions:

• Code the primary vaccine administration code (CPT 90460, 90471, or 90473), the diagnosis code and the EP modifier.

o CPT 90460 should be used to indicate face-to-face counseling was associated with the vaccine administration. CPT 90460 may be billed with more than one unit.

o CPT 90471 and CPT 90473 should be used when there is no face-to-face counseling associated with the vaccine administration. CPT 90471 and CPT 90473 must be billed with a unit value of “1.”

• Code the vaccine product code with the applicable diagnosis code and the EP modifier.

• Code the applicable add-on vaccine administration code (CPT 90472 or 90474) with the appropriate number of units, the diagnosis code and the EP modifier.


o CPT 90472 or CPT 90474 must be coded if more than one non-counseled vaccine was administered.

o CPT 90460 may be used in conjunction with the add-on vaccine administration codes CPT 90472 and CPT 90474 to indicate that first vaccine administered was counseled and the additional vaccines administered were non-counseled.

• Each vaccine administration code should be listed only one time per claim. If multiple vaccine product codes correspond to the same vaccine administration code, the vaccine administration code is listed once with the appropriate number of units indicated.

• The vaccine administration code should be billed with the appropriate charges as outlined in the Department of Community Health Check Services Manual.


Note: This vaccine administration claim example is incorrect for the following reasons:

1. Vaccine administration code CPT 90460 does not precede all vaccines on the claim.

2. Vaccine administration code CPT 90460 is billed with $0.00 charges. The vaccine administration code should be billed with the applicable allowed amount.

3. Vaccine product codes CPT 90744 and 90700 are billed with charges. Charges for vaccine administration should be appended to the vaccine administration code.

Coding for Immunization Administration: Component-based and Injection-based Coding

An immunization administration code must be reported in addition to the vaccine or toxoid product code in order to be paid for the administration service. There are 2 code sets that may be used when billing for administration, depending on the age of the patient and whether or not counseling was performed.

If the patient is 18 years of age or under, and counseling was performed by the physician or other qualified health care professional, component-based administration codes are used. These codes are based on the number of components in the vaccine, and a unit of administration is billed for each component. A component is defined as each disease for which the vaccine is intended to provide protection.

These codes apply to all routes of administration, including injectable, intranasal, and oral.

• 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 administered.

• 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.

• Example: All flu vaccines are intended to offer protection against 1 disease, influenza, and are considered single-component vaccines billed with 1 unit of 90460.

• Example: Pentacel vaccine is intended to protect against 5 diseases, diphtheria, tetanus, acellular pertussis, polio, and Haemophilus b influenza and is considered a 5-component vaccine. Bill 1 unit of 90460 and 4 units of 90461. If the patient is 19 years of age or over, or if they are 18 years of age or under and counseling was not performed, use the code set that is based on number of injections administered at that visit (90471–90472). Note that because all Sanofi Pasteur vaccines are injectable, only 90471 and 90472 are applicable. (Products administered via oral or intranasal use 90473-90474.)

• 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)

• Example: Fluzone and Adacel vaccines are administered to a patient that is 25 years of age. Bill 1 unit of 90471 for the Fluzone vaccine and

1 unit of 90472 for the Adacel vaccine


Immunizations and Vaccines

Immunizations Covered Under the Texas Vaccines for Children program

CPT Code Description

90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one 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.)

90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)

90632 Hepatitis A vaccine, adult dosage, for intramuscular use

90633 Hepatitis A vaccine, pediatric/adolescent dosage – 2-dose schedule, for intramuscular use

90634 Hepatitis A vaccine, pediatric/adolescent dosage – 3-dose schedule, for intramuscular use

90636 Hepatitis A and Hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use

90645 Haemophilus influenza b vaccine (Hib), HbOC conjugate (4-dose schedule), for intramuscular use

90646 Haemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use

90647 Haemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3-dose schedule), for intramuscular use

90648 Haemophilus influenza b vaccine (Hib), PRP-T conjugate (4-dose schedule), for intramuscular use

90649 Human Papilloma Virus (HPV) vaccine (Gardasil)*

*The HPV vaccine will be considered for reimbursement to Providers for patients ages 9 to 18 when the vaccine is not available through the Texas Vaccines for Children (TVFC) program. Providers should submit claims with the U1 modifier.

When billed without a modifier, the procedure code is informational only, allowing Providers to be paid the administration fee. In addition, the HPV vaccine will be payable to Providers who administer the HPV vaccine for patients ages 19 to 20.

Providers enrolled in TVFC must use TVFC as the source of the HPV vaccine for eligible patients when TVFC has HPV available for shipment.

CPT Description  Code

90655 Influenza virus vaccine, split virus, preservative free, for children 6–35 months of age, for intramuscular use

90657 Influenza virus vaccine, split virus, for children 6–35 months of age, for intramuscular use

90658 Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use

90669 Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use

90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for use in individuals younger than 7 years, for intramuscular use

90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use

90702 Diphtheria and tetanus toxoids (DT) adsorbed, for use in individuals younger than 7 years, for intramuscular use

90703 Tetanus toxoid absorbed, for intramuscular use

90705 Measles virus vaccine, live, for subcutaneous use

90706 Rubella virus vaccine, live, for subcutaneous use

90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

90710 Measles, mumps, rubella and varicella vaccine (MMRV)

90712 Poliovirus vaccine, any types (OPV), live, for oral use

90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular  use

90714 Tetanus and diphtheria toxoids (Td) absorbed, preservative free, for use in individuals 7 years or older, for intramuscular use

90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for use in individuals 7 years or older, for intramuscular use

90716 Varicella virus vaccine, live, for subcutaneous use

90718 Tetanus and diphtheria toxoids (Td) adsorbed, for use in individuals 7 years or older, for intramuscular use

90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Haemophilus influenza b vaccine (DTP-Hib), for intramuscular use

90721 Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Haemophilus influenza b vaccine (DtaP-Hib), for intramuscular use

90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immuno-suppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use

90733 Meningococcal polysaccharide vaccine (any groups), for subcutaneous use

90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use

90743 Hepatitis B vaccine, adolescent (2-dose schedule), for intramuscular use

90744 Hepatitis B vaccine, pediatric/adolescent dosage (3-dose schedule), for intramuscular use

90746 Hepatitis B vaccine, adult dosage, for intramuscular use

90748 Hepatitis B and Haemophilus influenza b vaccine (HepB-Hib), for intramuscular use

Modifier Description
SK Members of high-risk population

Immunization Administration Procedures Covered Under the TVFC Program


CPT Code Description Immunization Administration

90465 First injection, single or combination vaccine/toxoid, per day.

Immunization administration in patients younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family.

90466 Each additional injection, single or combination vaccine/toxoid, per day. (List separately in addition to code for primary procedure.)

90467 First administration, single or combination vaccine/toxoid, per day. Immunization administration in patients younger than 8 years of age (includes intranasal or oral routes of administration) when the physician counsels the patient/family.

90468 Each additional administration, single or combination vaccine/toxoid, per day. (List separately in addition to code for primary procedure.)

90471 One vaccine, single or combination vaccine/toxoid. Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections).

90472 Each additional vaccine, single or combination vaccine/toxoid. (List separately in addition to code for primary procedure.)

90473 One vaccine, single or combination vaccine/toxoid. Immunization administration(includes intranasal or oral route).

90474 Each additional vaccine, single or combination vaccine/toxoid (list separately in addition to code for primary procedure.).


INJECTIONS A CHILD RECEIVES IN ONE DAY.

A rule published in the Louisiana Register states: The Bureau of Health Services Financing does not reimburse providers for a single-antigen vaccine and its administration if a combinedantigen vaccine is medically appropriate and the combined vaccine is approved by the Secretary of the United States Department of Health and Human Services. (Louisiana Register, Volume 20, Number 3)


Reimbursement

In order for providers to receive reimbursement for the administration of appropriate immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) in the current Immunization Schedule, providers must indicate the CPT code for the specific vaccine in addition to the appropriate administration CPT code(s). The listing of the vaccine on
the claim form is required for federal reporting purposes.

For recipients age birth through 18 years, vaccine CPT codes will be paid at zero ($0) because the provider obtains the vaccine from the Vaccines for Children Program at no cost. For recipients age 19 through 20 years, providers should submit claims with their usual and customary charge for the vaccine and the claims will be reimbursed at the fee on file or the
billed charge, whichever is lower.

Billing For a Single Administration

Providers should bill the appropriate CPT 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 CPT code for the vaccine, with $0.00 in the “billed charges” column (see pg. 102 for an
example).

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

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


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 CPT administration codes should match the number of units listed in the units column. Examples of this scenario are on pages 103 through 107.

• Use CPT 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 CPT 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.

Coverage of Vaccines for Recipients Age 19 through 20 Years Louisiana Medicaid is in the process of updating programming for immunizations including the ACIP recommended vaccines for recipients aged 19 through 20 years of age (e.g. Human Papilloma Virus, Influenza). Providers will be notified when these changes have been implemented.

For recipients age19 through 20 years, providers should submit claims reporting the appropriate immunization administration CPT code along with the specific CPT code and their usual and customary charge for the vaccine administered. The claims will be reimbursed at the fee on file or the billed charge, whichever is lower for the vaccine and administration.

Pediatric Flu Vaccine: Special Situations

In the event a Medicaid provider does not have VFC pediatric influenza vaccine on hand to vaccinate a high priority VFC eligible Medicaid enrolled child, the provider should use pediatric influenza vaccine from private stock, if available. If a provider does use vaccine from private stock for a high priority VFC eligible Medicaid enrolled child, the provider would then replace dose(s) used from private stock with replacement dose(s) from VFC stock when VFC vaccine becomes available. The provider should not turn away, refer or reschedule a high priority VFC eligible Medicaid enrolled child for a later date if vaccine is available. Louisiana Medicaid will update Medicaid enrolled providers through remittance advices and the Louisiana Medicaid Provider Update regarding availability of vaccine through the VFC program and any billing issues. Please contact the Louisiana VFC Program office at (504)838-5300 for vaccine availability information.

IMMUNIZATIONS

A review of immunization status shall be performed at each well child visit, with immunizations  administered according to recommendations and standards of practice recognized by the AAP and th  Advisory Committee on Immunization Practices (ACIP). Providers are reminded that all immunizations must be reported to the Michigan Care Improvement Registry (MCIR). (Refer to the Directory Appendix for contact information.)

Immunizations are covered when administered according to ACIP recommendations. MDHHS encourages providers to immunize all Medicaid beneficiaries.

* For Medicaid eligible children 18 years of age and younger, the Vaccines for Children (VFC) Program provides covered immunizations at no cost to the provider.

* Medicaid covers immunizations for beneficiaries 19 years of age and older. * Any LHD in the state can be contacted for specifics about the VFC program.


For immunizations available free of charge under the VFC program, the amount a provider may charge for vaccine administration may be limited. Providers cannot charge more for services provided to Medicaid beneficiaries than for services provided to their general patient population. For example, if the charge for administering a vaccine to a private-pay patient is $5.00, then the charge for immunization administration to the Medicaid beneficiary cannot exceed $5.00.

Medicaid Health Plan (MHP) providers enrolled in the VFC program are encouraged to immunize and are discouraged from referring beneficiaries to a LHD for these services. (Refer to the Practitioner Chapter for additional information.)

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