TO:                  Physicians, Osteopaths, Mid-level Practitioners

Public Health Departments

 

FROM:            Kathleen P. Allyn, Deputy Administrator

           

   

Requirements of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), require transactions and codes be consistent throughout the nation.  Idaho, along with all other states, have used local state-only codes to pay for and report services not covered in the national coding books (HCPCS or CPT).  Idaho Medicaid, by becoming HIPAA compliant, will no longer be accepting reporting of the state-only codes for immunization services.

 

Effective for dates-of-service on or after September 1, 2003:  Two new modifiers have been created for vaccines provided through the Vaccines for Children (VFC) program.  Modifier SL must be billed with the CPT code for the vaccine and modifier U7 must be billed with administration code 90471.  Providers are no longer required to report additional vaccine administrations with CPT 90472.  These instructions only apply to vaccines supplied from the VFC program.

 

 

Administration of a Free Vaccine 

When only a free vaccine(s) is administered, the Medicaid claim must include the following information:

 

Ø      The appropriate CPT code for the vaccine with modifier SL billed at a zero dollar ($0.00) amount; and

Ø      Administration code 90471 with modifier U7 (one unit)

 

Note:  Administration services should be billed at the UCR (Usual and Customary Rate).

 

 

 

Administration of a Free Vaccine with an Evaluation and Management (E/M) Visit

When a free vaccine(s) is administered in conjunction with an E/M visit, the Medicaid claim must include the following information:

 

Ø      The appropriate CPT code for the vaccine with modifier SL billed at a zero dollar ($0.00) amount; and

Ø      Administration code 90471 with modifier U7 (one unit)

Ø      The appropriate CPT code for the E/M visit with modifier 25.  In order to bill the E/M code, documentation in the client’s record must reflect that additional services were rendered at the time the vaccine was given.  If reporting E/M visit with CPT 99201 or 99211, the administration (90471) is not separately billable but is considered inclusive within the E/M.

 

Note:  Administration and E/M services should be billed at the UCR (Usual and

Customary Rate)

 

 

Administration of a provider-purchased childhood vaccine with or without an E/M Visit

Services provided should be billed at the UCR (Usual and Customary Rate).  When a provider-purchased childhood vaccine is administered to a child less than twenty-one (21) years old, the Medicaid claim must include the following information:

 

Ø      The appropriate CPT or five-digit HCPCS code for the injectable vaccine; and

Ø      Administration code 90471 for the first vaccine and 90472 for each additional vaccine

Ø      And if applicable, the appropriate Evaluation and Management CPT code with modifier 25

 

 

Administration of a provider-purchased adult Vaccine with an E/M Visit

When an injection or adult vaccine is administered in conjunction with an E/M visit, Medicaid will pay only for the E/M visit and the vaccine.  The administration of the vaccine is inclusive in the E/M visit and not separately billable.  Services provided should be billed at the UCR (Usual and Customary Rate).  The Medicaid claim must include the following information:

 

Ø      The appropriate CPT or five-digit HCPCS code for the injectable vaccine; and

Ø      The appropriate Evaluation and Management CPT code billed at the UCR (usual and customary rate)

 

 

*if administering a provider-purchased adult vaccine without an E/M visit, bill with the HCPCS or CPT for the vaccine and 90471 and/or 90472, as appropriate.

 

 

 

Public Health Department Local/State Codes: Effective for dates-of-service on and after September 1, 2003, the local/state codes listed below will become obsolete.  Also listed are the appropriate CPT (Current Procedural Terminology) codes that correspond to the obsolete state codes.

 

Local/State Code	National CPT Code	Description
9633J	90633	Hepatitis A, pediatric/adolescent 2-dose schedule
9634J	90634	Hepatitis A, pediatric/adolescent 3-dose schedule
9647J	90647	Hemophilus influenza b vaccine (Hib) 3-dose schedule
9648J	90747	Hepatitis B vaccine, dialysis or immunosuppressed patients
9669J	90658	Influenza virus vaccine, split, age 3 years and above dosage
9699J	90471	Immunization administration
9700J	90700	Diphtheria, tetanus toxoids, acellular pertussis (DTaP)
9701J	90701	Diphtheria, tetanus toxoids, whole cell pertussis (DTP)
9702J	90702	Diphtheria, tetanus toxoids (DT); child less than 7 years old
9707J	90707	Measles, mumps rubella (MMR), live
9712J	90712	Poliovirus, (OPV), live, for oral use
9712J	90713	Poliovirus, (IPV), inactivated, for subcutaneous use
9716J	90716	Varicella virus, live
9718J	90718	Tetanus, diphtheria toxoids (Td); patient age 7 and older
9720J	90720	Diphtheria, tetanus toxoids, whole cell pertussis, hemophilus influenza B (DTP-Hib)
9731J	90744	Hepatitis B vaccine, pediatric/adolescent, 3-dose schedule
9731J	90746	Hepatitis B vaccine, adult
9737J	90645	Hemophilus influenza b (Hib) 4-dose schedule
9737J	90646	Hemophilus influenza b (Hib) booster use only
9737J	90647	Hemophilus influenza b (Hib) PRP-OMP conjugate 3-dose
9737J	90648	Hemophilus influenza b (Hib) PRP-T conjugate 4-dose
9742J	90371	Hepatitis B immune globulin (HBlg), human

 

If you have questions regarding the information in this notice, please contact Colleen Osborn (208) 364-1923.  Thank you for your continued participation in the Idaho Medicaid Program.