CO HCPF Immunizations Billing Manual — General Billing Information

RefertotheGeneralProviderInformationManuallocatedontheBillingManualswebpageorgeneralbillinginformation.

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Thefollowingcodesshouldbeusedforallvaccineadministration,includingVFCvaccineadministrationsformembersunder19yearsofage.Reportthesecodesinadditiontothevaccineandtoxoidcode(s).

CurrentProceduralTerminology(CPT)Code

UsethefollowingcodesforVFCvaccineadministrationtomembersunder19yearsofagewithface-to-facecounselingofthemember/familyduringthevaccineadministration:

90460

90461(usedtoindicatemulti-componentvaccinationswhenlistedinadditionto90460)

Usethefollowingcodesforvaccineadministrationtomembersofanyagewhentheadministrationisnotaccompaniedbyanyface-to-facecounseling,orforadministrationtomembersover18yearsofagewithorwithoutcounseling:

90471

+90472(Listseparatelyinadditionto90471,90473)

+90472

+90474(Listseparatelyinadditionto90471,90473)

Usethefollowingcodesfornirsevimabadministration

96380or96381

Use96380whentheadministrationisaccompaniedbyprovidercounseling.

Use96381whentheadministrationisnotaccompaniedbyprovidercounseling.Codeselectionisbasedonwhetheraproviderprovidedcounselingonthesamedateastheadministrationofnirsevimaborclesrovimab.

UsethefollowingcodeforvaccineadministrationtomembersofanyagewhenadministeringCOVID-19vaccines

90480

RefertotheImmunizationFeeSchedulelocatedontheProviderRatesandFeeScheduleswebpageforthemostup-to-daterateinformation.

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Thefollowingchartidentifiesthenumberofcomponentsinsomeofthecommonpediatricvaccinesandhowtoreportthepediatricimmunizationadministrationcodesforeachvaccine.

Table1

Vaccine

#ofComponents

WhichAdministrationCodestoReport?

HPV

1

90460

Influenza

1

90460

Meningococcal

1

90460

Pneumococcal

1

90460

Td

2

90460,90461

DTaPorTdap

3

90460,90461,90461

MMR

3

90460,90461,90461

DTaP-Hib-IPV

5

90460,90461,90461,90461,90461

DTaP-HepB-IPV

5

90460,90461,90461,90461,90461

DTaP-IPV

4

90460,90461,90461,90461

MMRV

4

90460,90461,90461,90461

DTaP-Hib

4

90460,90461,90461,90461

HepB-Hib

2

90460,90461

Rotavirus

1

90473

IPV

1

90460

Hib

1

90460

Source:AmericanAcademyofPediatrics

Tosubmitclaimsforimmunizationservices,providersmust"rollup/bundle"thetotalunitcountoftheimmunizationadministrationcodes.

Ifanimmunizationadministrationcodeisbilledforeachvaccinethatwasgivenduringthevisitasitsownlineitem,eachsubsequentlineitembilledusing90460aftertheinitial90460lineitemwillbedeniedasaduplicateclaim.

Example1:ThefollowingexampledemonstrateshowtobillfortheadministrationofHepA,DTaP-HIB-IPVandMMRvaccines.ComponentCalculationandwhichcodestoreportusingTable1Table2

Vaccine

#ofComponents

WhichCodestoReport?

HepA

1

90460

DTaP-HIB-IPV

5

90460,90461,90461,90461,90461

MMR

3

90460,90461,90461

HowtoBillTable3

Line#

CPTDescriptor

CPTCode

Units

Line1

FirstVaccineComponent

90460

3

Line2

AdditionalVaccineComponent

90461

6

Line3

HepA

90633

1

Line4

DTaP-HIB-IPV

90698

1

Line5

MMR

90707

1

CurrentProceduralTerminology(CPT)code90460isbilledforthree(3)unitsbecauseitwasreportedonceforeachvaccinethatwasadministered.

CPTcode90461isbilledforsix(6)unitsbecauseitwasreportedsix(6)times,four(4)timesfortheDTaP-HIB-IPVvaccineandtwo(2)timestheMMRvaccine).

VisittheAmericanAcademyofPediatrics(AAP)ChildHealthFinance&PaymentStrategywebpageforfurtherclarificationonbillingpediatricimmunizationcodes.

ContacttheProviderServicesCallCenterforbillingquestions.

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Theimmunizationadministrationcodes90471-90474needtobebilledasone(1)lineitem,andthevaccineproductshouldbebilledasaseparatelineitem.Inorderforanimmunizationclaimtobereimbursed,bothanadministrationcodeandthevaccineproductmustbebilled.Ifimmunizationistheonlyservicerendered,providersmaynotsubmitchargesforanEvaluationandManagement(E&M)service.

AdultimmunizationsarereimbursedatthelowerofbilledchargesortheHealthFirstColoradofeescheduleamountforeachimmunization.

Note:ProvidersarenottobillCPTcodes90471-90474forchildrenages0through18forwhomcounselingwasgiven.RefertotheUsingPediatricImmunizationCodes90460and90461sectioninthismanual.CPTCodes90471-90474mustonlybebilledformembersaged19andolderormembersaged18andunderforwhomnocounselingwasgiven.

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Thenirsevimabandclesrovimabadministrationcodes96380or96381mustbebilledasone(1)lineitem,andtheimmunizationproductshouldbebilledasaseparatelineitem.Foranimmunizationclaimtobereimbursed,bothanadministrationcodeandtheimmunizationproductcodemustbebilled.Ifimmunizationistheonlyservicerendered,providersmaynotsubmitchargesforanE&Mservice.

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HealthFirstColoradocoversvaccinecounselingvisitsinwhichhealthcareproviderstalktofamiliesabouttheimportanceofvaccination.

HealthFirstColoradoalsocoversandwillreimburseforstand-alonevaccinecounselingvisitsaspartofvaccineadministrationrequiredforallroutinevaccines.ProvidersshouldbillCPT90482,90483or90484forvisitsinwhichhealthcareprovidersgivecounselingabouttheimportanceofvaccination.ProvidersshouldincludemodifierCRforallCOVID-19vaccinecounseling-onlyvisits.

Providersshouldnotbillforthevaccinecounselingcodeandthevaccineadministrationcodeonthesamedateofservicewhenvaccineadministrationcodesareinclusiveofcounseling.

CPT90482,90483or90484canbebilledatonlyone(1)visitforeachmemberperday,buttherearenoquantitylimitsforthenumberoftimesthiseducationisprovidedtoanindividualmember.

Keepdocumentationinthemember'schartthatshowsthedurationofcounselingandalistofthepreventiontopicscoveredduringcounseling.

IfthereisaseparatelyidentifiableE&Mserviceperformedoutsideofvaccinecounselingandimmunizationadministration,aseparateE&Mvisitcodemaybereportedalongwithmodifier25.

Whenusingamodifierisappropriate,refertotheMedicaidNationalCorrectCodingInitiative(NCCI)webpageoftheCentersforMedicare&MedicaidServices(CMS)websiteforspecificguidanceontheproperuseofmodifiers.

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PharmacistsPharmacistsmustbillforvaccinationsonaprofessionalclaim(CMS1500)eitherviabatchthroughavendororthroughtheProviderWebPortalusingthepharmacy'sNPIasthebillingprovider,thepharmacist'sNPIastherenderingproviderandthephysicianonthestandingorderastheorderingprovider.

PharmaciesmusthaveaProviderWebPortalaccountbecausethepharmacistsdonotbill.Theyarestrictlytherendererontheclaims.

PharmaciescanaddapharmacisttotheirProviderWebPortalaccountasadelegateforthepurposeofsubmittingclaimsontheirbehalf.RefertotheDelegates-ProviderWebPortalQuickGuideforinstructions.

PharmaciescansubmitFFSclaimsviatheProviderWebPortalorbatchclaimsviathe837P.

IfthememberisenrolledinDenverHealthMedicaidChoiceorRockyMountainHealthPlansPrime,providersmustsubmittheclaimtotheMCO.

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ManagedCarePrograms(MCOs)

HealthFirstColoradomembersenrolledinanMCOmustreceiveimmunizationservicesfromtheMCO,andprovidersmaynotbillHealthFirstColoradodirectlyforvaccinesprovidedtothesemembers.

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Outpatient,EmergencyRoomorInpatientHospitalImmunizationadministrationmaybebilledaspartofanoutpatientoremergencyroomvisitwhenthevisitisformedicalreasons.

Outpatientoremergencyroomvisitscannotbebilledforthesolepurposeofimmunizationadministration.AdministrationofimmunizationatthetimeofaninpatientstayisincludedintheAllPatientsRefinedDiagnosisRelatedGroup(APR-DRG).

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FederallyQualifiedHealthCenters(FQHCs)andRuralHealthCenters(RHCs)

FederallyQualifiedHealthCenters(FQHCs)andRuralHealthCenters(RHCs)maybillanencounterfeeeveniftheonlyserviceprovidedisimmunizationadministrationbyabillableprovider,solongasthevisitotherwisequalifiesasabillableencounterper10CCR2505-108.700FQHCand8.740RHC.Ifimmunizationisadministeredinadditiontoaroutineofficevisit,thenanadditionalencounterfeemaynotbebilled.

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NursingFacilities

Nursingfacilityresidentsmayreceiveimmunizationsiforderedbytheirphysician.Theskillednursingcomponentforimmunizationadministrationisincludedinthefacility'srate.ThevaccineitselfmaybebilleddirectlytoHealthFirstColoradobyaHealthFirstColoradoenrolledpharmacy.ThepharmacymustbilltheappropriateNationalDrugCode(NDC)fortheindividualvaccinedoseunderthemember'sHealthFirstColoradoID.

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HomeHealthAmemberreceivinghomehealthservicesmayreceiveimmunizationsiftheadministrationispartofanormallyscheduledhomehealthvisit.Ahomehealthvisitforthesolepurposeofimmunizationadministrationisnotabenefit.

Thepharmacybillsthevaccineasanindividualdoseunderthemember'sColoradoHealthFirstColoradoID.Thehomehealthagencymaynotbillforthevaccine.

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AlternativeHealthCareFacilities(ACFs)/GroupHomes

ResidentsofanAlternativeHealthCareFacility(ACF)mayreceiveimmunizationsfromtheirownphysicians.Theymayalsoreceivevaccinesunderhomehealthasstatedaboveinthehomehealthguideline.

HealthFirstColoradodoesnotpayforhomehealthagencies,physiciansorothernon-physicianpractitionerstogotonursingfacilities,grouphomesorresidentialtreatmentcenterstoadministerimmunizations(e.g.,fluvaccines)togroupsofmembers.

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ForMedicarecrossoverclaims,HealthFirstColoradopaystheMedicaredeductibleandcoinsuranceorHealthFirstColoradoallowablereimbursementminustheMedicarepayment,whicheveramountisless.IfMedicare'spaymentforimmunizationservicesisthesameorgreaterthantheHealthFirstColoradoallowablebenefit,noadditionalpaymentismade.

IfMedicarepays100%oftheMedicareallowable,HealthFirstColoradomakesnoadditionalpayment.

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Vaccinesapprovedforself-administrationareacoveredbenefit.Whenadministeredbyahealthcareprovider,theclaimmustincludetheCurrentProceduralTerminology(CPT)codeforthevaccineproduct,aswellasthecorrespondingadministrationCPTcode.Whenself-administered,oradministeredbythemember’scaregiver,theclaimshouldcontainonlyavaccineproductCPTcode.

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RefertotheAppendixB-VaccinesforChildren(VFC)Programsectionofthismanual.

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EffectiveApril1,2014,theDepartmentwillnolongerreimburseNCCIProcedure-to-Procedure(PTP)editswhenimmunizationadministrationprocedurecodes(CPT90460-90474)arepairedwithpreventivemedicineE&Mserviceprocedurecodes(CPT99381-99397).

IfasignificantseparatelyidentifiableE&Mservice(e.g.,neworestablishedmemberofficeorotheroutpatientservices[99201-99215],officeorotheroutpatientconsultation[99241-99245],emergencydepartmentservice[99281-99285],preventivemedicineservice[99381-99429]isperformed),theappropriateE&Mservicecodeshouldbereportedinadditiontothevaccineandtoxoidadministrationcodes.

EachNCCIPTPedithasanassignedmodifierindicator.Amodifierindicatorof0"indicatesthatNCCIPTP-associatedmodifierscannotbeusedtobypasstheedit.Amodifierindicatorof1"indicatesthatNCCIPTP-associatedmodifiersmaybeusedtobypassaneditunderappropriatecircumstances.Amodifierindicatorof9"indicatesthattheedithasbeendeletedandthemodifierindicatorisnotrelevant.TheCorrectCodingModifierIndicatorcanbefoundinthefilescontainingHealthFirstColoradoNCCIPTPeditsontheMedicareNCCIEditswebpageoftheCentersforMedicare&MedicaidServices(CMS)website.

AmodifiershouldnotbeaddedtoaHealthcareCommonProcedureCodingSystem(HCPCS)/CPTcodesolelytobypassanNCCIPTPeditiftheclinicalcircumstancesdonotjustifyitsuse.IftheE&Mserviceissignificantandseparatelyidentifiableandperformedonthesameday,theE&McodeshouldbebilledwiththevaccineandtoxoidadministrationcodesusingPTPassociatedmodifier'25.'Modifier'25'isonlyvalidwhenappendedtotheE&Mcodes.Donotappendtotheimmunizationadministrationprocedurecodes90460-90474.

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COVID-19vaccinesareusedtopreventSevereAcuteRespiratorySyndromeCoronavirus2(SARS-CoV-2)viralinfectionsandthediseasetheycause,Coronavirusdisease(COVID-19).AllFDA-approvedCOVID-19vaccinesareacoveredbenefitforallHealthFirstColoradoMemberswithoutcost-sharingandwithoutpriorauthorization.ThisincludesCOVID-19vaccinesapprovedunderanEmergencyUseAuthorization(EUA).Ifprovidersreceivethevaccineproductatnocost,HealthFirstColoradowillreimburseforvaccineadministrationonly.Providersservingadultmembers(aged19andup)mayalsoseekreimbursementforcommerciallypurchasedCOVID-19vaccineproductsinadditiontovaccineadministration.Aproductcode,aswellasanadministrationcode,mustalwaysbeincludedinanyclaimsforvaccination.EffectiveSeptember11,2023,pediatricCOVID-19vaccinesarepartoftheVFCProgramandmustbeadministeredbyaVFC-enrolledproviderusingVFCvaccineproducts.

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Synagis®(Palivizumab)isusedtopreventseriouslowerrespiratorytractdiseasecausedbyRespiratorySyncytialVirus(RSV)incertainhigh-riskpediatricmembers.TheDepartmentusescoveragecriteriabasedontheAmericanAcademyofPediatrics(AAP)2014andtheColoradoChapteroftheAAPrecommendationsforRSVprophylactictherapy.Synagis®(Palivizumab)isnotprovidedbytheVFCProgram.

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LimitationsonSynagis®

Synagis®isadministeredbyintramuscularinjections,at15mgperkgofbodyweight,onceamonthduringexpectedperiodsofRSVfrequencyinthecommunity.Synagis®administrationmustbepriorauthorized.MemberswhohavereceivednirsevimaborclesrovimabmaynotreceivesubsequentSynagis®inthesameseason.

Synagis®seasonusuallybeginsinthefall.RefertotheannualSynagis®providerbulletinontheProviderBulletinswebpageformoreinformation.

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BillingforSynagis®

TheDepartmentwillprovidepricinginformationduringeachSynagis®season.

ProvidersmaynotaskmemberstoobtainSynagis®fromapharmacyandbringittothepractitioner'sofficeforadministration.

Synagis®giveninadoctor'soffice,hospitalordialysisunitistobebilleddirectlybythosefacilitiesasamedicalbenefit.PriorAuthorizationRequests(PARs)forSynagis®billedasamedicalbenefitshallbesubmittedtothefeeforserviceUtilizationManagement(UM)vendorviatheironlinePARportal,Atrezzo.

Synagis®mayonlybeapharmacybenefitifthemedicationisadministeredinthemember'shomeorlong-termcarefacility.

Note:AseparateSynagis®PARprocessexistsfortheChildHealthPlanPlus(CHP+)StateManagedCareNetworkmembers.AnyquestionsregardingthisprocessshouldbedirectedtoColoradoAccessat303-751-9005or800-511-5010,orUSBioservicesat303-706-0053.

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NirsevimabandclesrovimabaremonoclonalantibodiesforthepreventionofRespiratorySyncytialVirus(RSV)lowerrespiratorytractdisease.TheyareavailablethroughtheVFCProgramforprovidersenrolledintheprogramtoadministertoHealthFirstColoradoenrolledchildren.Itdoesnotrequirepriorapproval.Reporttheadministrationofnirsevimaborclesrovimabwithcodes96380or96381.Donotreportimmunizationadministrationcodes90461–90462or90471–90472fortheinjectionofnirsevimaborclesrovimab.MemberswhohavereceivednirsevimaborclesrovimabmaynotreceivesubsequentSynagisinthesameseason.

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Seasonalinfluenzavaccineisabenefitforchildrenandadultsandisrecommendedforindividualswhoaresix(6)monthsofageorolder.InfluenzavaccineisavailablethroughtheVFCProgramforprovidersenrolledintheprogramtoadministertoHealthFirstColorado-enrolledchildren/adolescents(under19yearsofage).RefertotheAppendixB-VaccinesforChildren(VFC)Programsectioninthismanual.

RefertotheannualSynagis®andInfluenzaVaccinesproviderbulletinlocatedontheProviderBulletinswebpageformoreHealthFirstColoradoinformationontheseasonalinfluenzavaccineforbothchildrenandadults.

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TheVFCProgram,administeredbyCDPHE,partnerswithHealthFirstColoradotoprovidefreevaccinesforproviderstoadministertoHealthFirstColorado-enrolledchildren.

ParticipationintheVFCProgramisstronglyencouragedbytheDepartment.VFCparticipationisrequiredforreimbursementforadministrationofvaccinestomembersunder19yearsofage.Providers,includingbutnotlimitedtoprivatepractitioners,managedcareproviders,localpublichealthagencies,RHCs,hospitaloutpatientclinics,school-basedhealthcenters,pharmaciesandFQHCs,whowishtoparticipateintheimmunizationprogrammustenrollwithCDPHE.VisittheVaccinesforChildrenwebpageorcall303-692-2650forinformationontheCDPHEVFCProgram.

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