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MHS Vaccine Reimbursement Procedures

Date: 05/30/17

MHS would like to remind providers of the procedures for billing vaccines.

VFC Vaccines

All children under the age of 18 are eligible for vaccines distributed via the Vaccine for Children (VFC) program. Free vaccines available through VFC are for the following diseases:

Diphtheria

Influenza

Pertussis

Hemophilus influenza type B

Measles

Pneumococcal Disease

Hepatitis A

Meningococcal disease

Polio

Hepatitis B

Mumps

Rotavirus

Human Papilloma virus

Rubella

Tetanus

Varicella

  


Since VFC vaccine is at no cost to the provider, reimbursement is allowed for the vaccine administration. The IHCP rate for administration is $8 and is reimbursable at the lesser of billed charges or $8.[1] However, provider must bill in the following manner:

  • Appropriate diagnosis code based on DOS – V20.2 for DOS September 30, 2015 and prior and Z00.121 or Z00.129 for DOS October 1, 2015 and after
  • Procedure code with specific vaccine administered with a billed amount of $0.00
  • Appropriate vaccine administration code with the SL modifier. (90471 – 90474)

Claims may be billed as a stand-alone service, with a preventive visit (CPT 99381 – 99385 or 99391 – 99395), or as an evaluation and management (E/M) code if medically appropriate (CPT 99211 – 99215). If a member is in the office for an E/M and in need of a vaccine, please remember that the E/M code must be billed with a 25 modifier. If the modifier is not used, the administration code will be denied.

Private Stock for Vaccines

Effective June 1, 2017, providers may bill for vaccines available from the VFC but provided out of private stock, as well as for vaccines that are not available under the VFC program. Providers may bill for both the vaccine and the administration code as follows:

  • Procedure code with specific vaccine administered with usual and customary billed amount
  • Administration code using CPT code 90471-90474 with usual and customary billed amount

If an E/M service code is billed on the same date of service, the administration code will not be separately reimbursed. Separate reimbursement is only allowed when the administration of the vaccine is the only service provided.

 

[1] For contracted providers reimbursement will be in accordance with contract



Last Updated: 05/30/2017