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 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
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 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.
National CPT Code
Hepatitis A, pediatric/adolescent 2-dose schedule
Hepatitis A, pediatric/adolescent 3-dose schedule
Hemophilus influenza b vaccine (Hib) 3-dose schedule
Hepatitis B vaccine, dialysis or immunosuppressed patients
Influenza virus vaccine, split, age 3 years and above dosage
Diphtheria, tetanus toxoids, acellular pertussis (DTaP)
Diphtheria, tetanus toxoids, whole cell pertussis (DTP)
Diphtheria, tetanus toxoids (DT); child less than 7 years old
Measles, mumps rubella (MMR), live
Poliovirus, (OPV), live, for oral use
Poliovirus, (IPV), inactivated, for subcutaneous use
Varicella virus, live
Tetanus, diphtheria toxoids (Td); patient age 7 and older
Diphtheria, tetanus toxoids, whole cell pertussis, hemophilus influenza B (DTP-Hib)
Hepatitis B vaccine, pediatric/adolescent, 3-dose schedule
Hepatitis B vaccine, adult
Hemophilus influenza b (Hib) 4-dose schedule
Hemophilus influenza b (Hib) booster use only
Hemophilus influenza b (Hib) PRP-OMP conjugate 3-dose
Hemophilus influenza b (Hib) PRP-T conjugate 4-dose
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.