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MHS Vaccine Reimbursement Procedures effective with date of service January 1, 2020

Date: 01/03/20

Recently, FSSA updated the reimbursement policy for vaccines in BT201960 and BR201948. MHS would like to remind providers of the procedures for billing vaccines

VFC Vaccines

All members under the age of 19 are eligible for vaccines distributed via the Vaccine for Children (VFC) program. Free vaccines available through VFC as outlined In BR201948 and below:

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

  

For a complete list of CPT® codes, please refer to BR201948.

Since VFC vaccine is at no cost to the provider, reimbursement is allowed for the vaccine administration. The IHCP rate for administration is $8 for dates of service prior to January 1, 2020 and $15 after January 1, 2020 and is reimbursable at the lesser of billed charges or the IHCP fee.[1]

However, to receive reimbursement for the administration, providers must bill in the following manner:

  • Appropriate diagnosis code of Z00.121 or Z00.129
  • Procedure code with specific vaccine administered, preferably with a billed amount of $0.00.  Regardless of amount billed, the service line will be reimbursed at $0
  • Appropriate vaccine administration CPT® code 90471 - 90474 with the SL modifier.

Claims billed for VFC vaccine administration codes without the SL modifier will be denied EXs9 – VFC modifier omitted from billing, please correct and resubmit.

Claims billed for VFC vaccines that are billed only with the administration code and not the appropriate vaccine code will deny EXVC – Must be billed with vaccination code.

Claims may be billed as a stand-alone service OR with an office visit. If a member is in the office for an E/M visit and in need of a vaccine, please remember that the E/M code should be billed with a 25 modifier.

Private Stock for Vaccines

Effective January 1, 2020, providers will no longer be reimbursed for vaccines available through the VFC but provided out of private stock.  Claims billed for vaccines available through the VFC will be reimbursed at $0.  

Provider may bill for vaccines that are not available through the VFC program. Providers may bill for both the vaccine and the administration code as follows:     

  • Vaccine procedure code with specific vaccine administered with usual and customary billed amount
  • Administration 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 (DOS) as the vaccine administration, the vaccine administration code will not be separately reimbursed, even if the E/M is billed with a modifier 25.  For private stock vaccines, separate reimbursement for CPT® 90471-90474 is only allowed when the vaccine and the administration of the vaccine are the only services provided for the DOS.

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

CPT® is a registered trademark of the American Medical Association (AMA). All rights reserved



Last Updated: 01/03/2020