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November 22, 2006
 
MEDICAID INFORMATION RELEASE #MA06-39
 
 
To:                  Physicians, Osteopaths, Mid-level Practitioners,   Public Health Departments
 
From:               Leslie M. Clement, Administrator
                       Division of Medicaid
 
Subject:           Change in Policy on billing for Immunizations
 
This IR replaces IR #2003-45 (Immunization Guidelines)
 
Medicaid is changing the reimbursement policy for administration of free vaccines. For claim dates of services on or after February 1, 2007, use the following guidelines when billing for vaccines and/or administration services.    All vaccine services should be billed at the Usual and Customary Rate providers use to bill for non-Medicaid patients.
 
vaccine services provided
 
 
billing instructions for children
(The free vaccine program is available for participants until their 19th birthday.)
 
 
billing instructions for adults
(Free vaccine is not available for those who have reached their 19th birthday.)
 
Administration of                free vaccine only:
  • Bill the appropriate CPT code for the vaccine(s) using modifier SL with a zero dollar ($0.00) amount; and
  • The CPT code in the range of 90465 to 90474 that accurately reflects the administration of the vaccine(s).
  • Not applicable – there is no free vaccine program for adults
Administration of                  free vaccine and,
if there is a significant, separately identifiable service,
Evaluation and Management
(E&M) visit:
 
  • Bill the appropriate CPT code for the vaccine(s) using modifier SL with a zero dollar ($0.00) amount; and
  • The CPT code in the range of 90465 to 90474 that accurately reflects the administration of the vaccine(s), and
  • The appropriate CPT code for the E/M visit with modifier 25.  
  • Not applicable – there is no free vaccine program for adults
Administration of  provider-purchased vaccine only:
  • Bill the appropriate CPT code for the vaccine(s) without a modifier, and
  • The CPT code in the range of 90465 to 90474 that accurately reflects the administration of the vaccine.
 
  • Bill the appropriate CPT code for the vaccine(s) without a modifier, and
  • The CPT code in the range of 90471 to 90474 that accurately reflects the administration of the vaccine.
Administration of provider-purchased vaccine, and,
if there is a significant, separately identifiable service,
Evaluation and Management
(E&M) visit:
 
  • Bill the appropriate CPT code for the vaccine(s) without a modifier, and
  • The CPT code  in the range of 90465 to 90474 that accurately reflects the administration of the vaccine, and if applicable,
  • The appropriate CPT code for the E/M visit with modifier 25.   
  • Bill the appropriate CPT code for the vaccine(s) without a modifier, and
  • The CPT code  in the range of 90471 to 90474 that accurately reflects the administration of the vaccine, and if applicable,
  • The appropriate CPT code for the E/M visit with modifier 25.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note:  The U7 modifier is no longer necessary.  Effective February 1, 2007 claims with the U7 modifier will be denied.
 
IDAHO MEDICAID PROVIDER HANDBOOK
This Information Release updates Section 3 of your Idaho Medicaid Provider Handbook.
 
If you have questions regarding this information, please contact Jeanne Siroky in the Bureau of Medical Care at (208) 364-1897.  Thank you for your continued participation in the Idaho Medicaid program.