Status
Active
Reimbursement Policy
Section:
General Coding Section
Policy Number:
RP-General Coding-037 – Immunizations/Vaccines
Effective Date:
July, 2016
Immunizations/Vaccines
Description:
An immunization or vaccine provides protection of susceptible patients
from communicable diseases by administration of a living modified agent,
a suspension of killed organisms, a protein expressed in a heterologous
organism, or an inactivated toxin.
Definitions:
Immunization administration codes:
90460-90461
90471-90474
G0008-G0010
Immunization/Vaccine codes:
90476-90749
Q2034-Q2039
State supplied vaccine modifier:
-SL
Policy:
The vaccine products are separately identified in CPT and HCPCS Level II
(codes 90476-90749, Q2034-Q2039). Submit the code that describes the
immunization administered. Some immunization codes are combination
codes that reflect more than one type of vaccine. If administering a
combination vaccine, it is inappropriate to code each component
separately.
The immunization administration code(s) 90460-90461, 90471-90474 or
G0008-G0010 must be reported in addition to the vaccine and toxoid
code(s) 90476-90749, Q2034-Q2039.
Immunization Administration Add-ons
The immunization administration codes 90460-90461, 90471-90474 or
G0008-G0010 are reported in addition to the vaccine or toxoid code(s)
90476-90749, Q2034-Q2039. When giving more than one vaccine/toxoid,
multiple administration codes are reported. But it is important to choose
the correct add-on administration code. The following are the correct
reporting of single and combinations of administration codes.
1
Immunizations/Vaccines
Administration services 90472 and 90474 are considered add-on codes.
2
Type of
vaccine/toxoid
administration(s)
injection, oral or
intranasal
injection
Is there more
than one
vaccine/toxoid?
No
Is
counseling
included?
Yes
Correct
administration
code(s)
90460
No
No
injection, oral or
intranasal
Yes
Yes
injection
Yes
No
oral or intranasal
oral or intranasal
No
Yes
No
No
injection and
oral/intranasal
Yes
No
injection and
oral/intranasal
Yes
Mixed
(One or
more
90471, G0008,
G0009 or
G0010
90460 and
90461 (X # of
additional
vaccines/toxoid
components)
90471, G0008,
G0009 or
G0010 and
90472 (X # of
additional
vaccines/toxoid
components)
90473
90473 and
90474 (X # of
additional
vaccines/toxoid
components)
90471, G0008,
G0009 or
G0010 and
90474 (X # of
additional
oral/intranasal
vaccines/toxoid
components) or
90473 and
90472 (X # of
additional
injected
vaccines/toxoid
components)
Counseling
included -90460 and/or
Immunizations/Vaccines
vaccine
administered
including
counseling
and one or
more
vaccine
administered
without
counseling)
90461 (X # of
additional
vaccines/toxoid
components)
and
Counseling not
included -90474 (X # of
additional
oral/intranasal
vaccines/toxoid
components)
and/or
90473 and
90472 (X # of
additional
injected
vaccines/toxoid
components)
Immunizations with Evaluation and Management (E/M) services
If only a vaccine immunization is administered, bill only the code for the
vaccine/toxoid administered and the applicable administration code.
However, reimbursement for vaccines/toxoids and immunization
administration may be allowed in addition to preventive medicine services
(99381-99387, 99391-99397, 99401-99404), newborn care services
(99460-99463), and illness-related E/Ms (99201-99205, 99212-99215).
Supplies Used in Conjunction with Immunization Administrations
Syringes, needles or other supplies (A4206-A4209) used in conjunction
with administering any injection, including immunizations, are considered
integral to that administration and will be denied as incidental to the
administration.
MHCP* (Public Programs) Policy
*MHCP policy takes precedence over the general policy above when
processing claims for MHCP subscribers.
Serum from Department of Human Services
If receiving serum from the Minnesota Vaccine for Children Program for
child immunizations, the provider should bill Blue Cross for the
administration charge only. Providers should submit the immunization
code with an –SL modifier to indicate the serum was received from DHS.
Providers are required to obtain serum from DHS for all PMAP enrollees.
The administration codes 90460-90461, 90471-90474 or G0008-G0010
3
Immunizations/Vaccines
must be reported in addition to the vaccine. If the vaccine code is
submitted it should be reported with a zero charge. Blue Cross will allow
the line to be submitted with a $0.01 charge if the provider’s billing
systems or services cannot accommodate a zero charge.
Minnesota Health Care Programs (MHCP) payment for vaccine
administration code 90461
Blue Plus is following the DHS guidelines for payment of vaccine
administration. Based upon these guidelines, only the single or first
vaccine/toxoid component will be reimbursed for Blue Plus MHCP
subscribers. Blue Plus reminds providers that claim lines submitted for
MHCP subscribers with procedure code 90461 are being denied as part of
the basic service. See DHS provider communication below.
MHCP-covered Immunization Administration (vaccines/toxoids). Use
the following codes to report immunization administration in conjunction
with each single or combination vaccine/toxoid code reported.
Code
90471
90472
Each additional
vaccine
90473
First vaccine
(single or
combination)
Each additional
vaccine
90474
4
Used to report
administration of:
First vaccine
(single or
combination)
Administration
route:
Percutaneous,
intradermal,
subcutaneous,
intramuscular
Percutaneous,
intradermal,
subcutaneous,
intramuscular
Oral, intranasal
MHCP
limitations:
Do not use with
90473
Oral, intranasal
Use with 90471
or 90473; list
separately
18 years &
younger
Physician/health
care professional
counseling
required
List separately
Use only with
90460 (when
performing
physician/health
care professional
90460
Single or first
vaccine/toxoid
component of
combination
vaccine
Any
90461
Each additional
component of
combination
vaccine
Any
Use with 90471
or 90473; list
separately
Do not use with
90471
Immunizations/Vaccines
counseling)
*There is no
additional
reimbursement
for the
administration of
the additional
components of a
combination
vaccine.
*Centers for Disease Control and Prevention (CDC) considers the
Vaccines for Children (VFC) administration reimbursement amount to be
paid on a per injection basis, not a per component basis.
DHS website reference
To view the DHS specific information go to the following link:
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DY
NAMIC_CONVERSION&RevisionSelectionMethod=LatestRe
leased&Redirected=true&dDocName=id_000094
Subscribers impacted
This applies to subscribers enrolled in the following Blue Plus plans:
Product name
Blue Advantage (PMAP)
18 years and younger
MinnesotaCare
18 years and younger
Medicare Advantage Policy and Medicare Cost Plan
Flu Vaccines
The influenza vaccine codes Q2034-Q2039 were added for Medicare to
identify specific flu vaccine products. Additionally, Medicare instructed
that the existing CPT vaccine code 90658 would no longer be allowed.
Medicare Advantage plan will follow Medicare’s requirements.
Commercial plans will continue to accept 90658 as well as the new flu
vaccine codes. However, edits will be instituted.
Only one flu vaccine code will be accepted: 90658, Q2034, Q2035,
Q2036, Q2037 or Q2038. Code Q2039 should not be submitted. If the
vaccine is not specific to the products noted in codes Q2034-Q2038, Blue
Cross expects the code 90658 to be submitted in lieu of the unlisted code
Q2039. As a general policy, claims may be subject to denial when an
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Immunizations/Vaccines
unlisted code is submitted when a definitive code exists. Such would be
the case for code Q2039.
Billing Options for Medicare Part D Vaccines
There is an online option for processing Medicare Part D vaccine claims
electronically. eDispense Part D Vaccine Manager, a product of
Dispensing Solutions Inc. (DSI), is a web portal that provides physicians
or qualified healthcare practitioners with real-time claims processing for
in-office administered vaccines. This system also allows providers to
electronically bill for Part D vaccine administration charges. eDispense
Part D Vaccine Manager allows physicians or qualified healthcare
practitioners to bill Blue Plus (through its pharmacy benefit manager,
Prime Therapeutics) online for all Part D vaccines like Zostavax, on behalf
of SecureBlue, MedicareBlueSM Rx (PDP) and MedicareBlue PPO
(Regional PPO) subscribers.
Physicians or qualified healthcare practitioners can submit claims for Part
D vaccines and/or Part D vaccine administration in two ways: either
electronically through the eDispense website or by using a HICF-1500 and
following a paper claims process.
Medicare B versus Medicare D
Influenza, hepatitis B and pneumococcal vaccines are allowable and billed
under Medicare part B. Any other vaccine administered in the office place
of service, like a shingle vaccine, will be denied. The subscriber will have
to submit the vaccine to a Medicare part D carrier.
Some vaccines received at a pharmacy may be allowed if rendered due to a
medical reason, for example a tetanus shot.
Enrolled with DSI
If you have enrolled with DSI (Part D electronic clearinghouse) to use their
eDispense claims system, you can submit claims for vaccines and vaccine
administration through their website. This website will also allow you to
check subscriber eligibility for various Part D vaccines, as well as to
determine the applicable subscriber copays, if any.
Additional Information
For more information on eDispense and how to sign up to use that system,
visit: https://enroll.edispense.com/ws_enroll or call DSI at 1-866-5223386. You can also go to bluecrossmn.com and type “eDispense” in the
search option.
Paper Claims
6
Immunizations/Vaccines
If you decide not to enroll in eDispense, you can use a HICF-1500 form to
submit claims for vaccines and administration. If you submit a paper
claim, it must include:
NDC number for the vaccine
Quantity
day’s supply is reported using (1) unit
Paper claims for SecureBlue subscribers can be submitted to:
Blue Plus
P.O. Box 64813
St. Paul, MN 55164
For the regional products, MedicareBlue Rx or MedicareBlue PPO, please
use the name of the product as the addressee when submitting paper
claims:
MedicareBlue Rx or MedicareBlue PPO (whichever is appropriate)
P. O. Box 64813
St. Paul, MN 55164
If you have questions regarding claims submitted for the regional products,
call the subscriber services number on the back of the subscriber’s ID card.
Documentation
Submission:
Documentation must identify and describe the vaccine(s), route of
administration and details of the counseling, if performed. If the
vaccine(s) was administered at the same visit as an E/M, counseling is
normally part of the E/M.
Coverage:
Coverage for immunizations is subject to the subscriber’s contract benefits.
The following applies to all claim submissions.
All coding and reimbursement is subject to all terms of the Provider
Service Agreement and subject to changes, updates, or other requirements
of coding rules and guidelines. All codes are subject to federal HIPAA
rules, and in the case of medical code sets (HCPCS, CPT, ICD), only
codes valid for the date of service may be submitted or accepted.
Reimbursement for all Health Services is subject to current Blue Cross
Medical Policy criteria, policies found in the Provider Policy and
Procedure Manual sections, Reimbursement Policies and all other
provisions of the Provider Service Agreement (Agreement).
In the event that any new codes are developed during the course of
Provider's Agreement, such new codes will be paid according to the
standard or applicable Blue Cross fee schedule until such time as a new
agreement is reached and supersedes the Provider's current Agreement.
All payment for codes based on Relative Value Units (RVU) will include a
site of service differential and will be calculated using the appropriate
7
Immunizations/Vaccines
facility or non-facility components, based on the site of service identified,
as submitted by Provider.
Coding:
The following codes are included below for informational purposes only,
and are subject to change without notice. Inclusion or exclusion of a code
does not constitute or imply subscriber coverage or provider
reimbursement.
CPT/HCPCS Modifier: SL
ICD Diagnosis: N/A
ICD Procedure: N/A
HCPCS: 90460-90461, 90471-90474, 90476-90749, G0008-G0010,
Q2034-Q2039
Deleted Codes: N/A
Policy History:
Initial Committee Approval Date: June 9, 2016
Most recent history:
Cross
Reference:
None
Current Procedural Terminology (CPT®) is copyright 2016 American Medical
Association. All Rights Reserved. No fee schedules, basic units, relative values, or
related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
Copyright 2016 Blue Cross Blue Shield of Minnesota.
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Immunizations/Vaccines