HCPCS: G0010
ICD-10: Acute Hep B B16, Chronic viral Hep B with delta agent B18.0, Chronic viral Hep B w/o delta agent B18.1,
Unspecified viral Hep B B19.1, Carrier of viral Hep B Z22.51
Component or Mutually Exclusive Code Individual vaccines billed on same date. Bundling Guideline
90723 90700, 90713, 90740, 90743, 90744, 90746, 90747 All codes are components of 90723
90636 or 90748 90740 or 90743 90740 or 90743 are components of 90636 or 90748
90743 90740 Mutually exclusive of 90743
90744 90740 Mutually exclusive of 90743
90746 90740 Mtually exclusive of 90743
90747 90740 Mutually exclusive of 90743
These codes are for reporting of the vaccines only. The provider bills for the administration of the vaccines using HCPCS code G0008 for the influenza virus vaccine, G0009 for the PPV vaccine, and G0010 for the hepatitis B vaccine.
D. Applicable Bill Types.–Bill types 13X, 22X, 23X, 34X, 72X, 75X, and 85X are the only bill types acceptable when billing for influenza and PPV. When billing for hepatitis B, the applicable bill types are 13X, 22X, 23X, 34X, 71X, 72X, 73X, 75X and 85X.
E. Applicable Revenue Codes.–All providers listed in subsection B with the exception of RHCs and FQHCs bill you for the vaccines using revenue code 636 and for the administration of the vaccines using revenue code 771. RHCs and FQHCs follow subsection B for influenza and PPV and bill hepatitis B just like any other RHC/FQHC service using revenue code 52X (freestanding clinic).
F. Other Coding Requirements.–The provider must report a diagnosis code for each vaccine if the sole purpose for the visit is to receive a vaccine or if a vaccine is the only service billed on a claim. Providers report code V04.8 for the influenza virus vaccine, code V03.82 for PPV, and code V05.3 for the hepatitis B vaccine. In addition, for the influenza virus vaccine providers report UPIN code SLF000 if the vaccine is not ordered by a doctor of medicine or osteopathy and enters condition code M1 in FLs 24-30 when roster billing. (See subsections L and N for a more detailed explanation of roster billing.)
G. Special Instructions for Independent and Provider-based RHCs/FQHCs.–Independent and provider-based RHCs and FQHCs do not include charges for influenza and PPV on Form HCFA- 1450. They count visits under current procedures except they do not count as visits when the only service involved is the administration of influenza and PPV. If there was another reason for the
o Where a beneficiary does not meet the eligibility criteria for home health coverage, a home health nurse may be paid for the vaccine (influenza, PPV or hepatitis B) and its administration. No skilled nursing visit charge is billable. Administration of the services should include charges only for the supplies being used and the cost of the injection. Do not pay for travel time or other expenses (e.g., gasoline). In this situation, the HHA bills under bill type 34X and reports revenue code 636 along with the appropriate HCPCS code for the vaccine and revenue code 771 along with the appropriate HCPCS code for the administration.
If a beneficiary meets the eligibility criteria for coverage, and their spouse does not, and the spouse wants an injection the same time as a nursing visit, instruct your HHAs to bill in accordance with the bullet point above.
I. Special Billing Instructions for Hospital Inpatients.–When vaccines are provided to inpatients of a hospital, they are covered under the vaccine benefit. However, the provider bills you on bill type 13X using the discharge date of the hospital stay to avoid editing in the Common Working File (CWF) as a result of hospital bundling rules. (See subsection M for an exception.)
J. Special Billing Instructions for Hospices.–Hospices can provide the influenza virus, PPV, and hepatitis B vaccines to those beneficiaries who request them including those who have elected the hospice benefit. These services are coverable when furnished by the hospice. Services for the vaccines should be billed to the local carrier on the HCFA-1500. Payment will be made using the same methodology as if they were a supplier. Hospices that do not have a supplier number should contact their local carrier to obtain one in order to bill for these benefits.
K. Payment Procedures for CORF and ESRD Facilities.–Make payment for PPV and influenza vaccines for CORFs and independent ESRD facilities based on the lower of the actual charge or 95 percent of the average wholesale price (AWP). Deductible and coinsurance do not apply. Contact your carrier to obtain information in order to make payment for the administration of
Revised Editing for Hepatitis B Administration Code G0010
• HCPCS code G0010 Administration of hepatitis B vaccine
In CR 7342, Transmittal 2174, dated March 18, 2011, CMS retroactively assigned HCPCS code G0010 to APC 0436, Level I, Drug Administration, and changed the status indicator for HCPCS code G0010 from status indicator “B” to status indicator “S” effective January 1, 2011.
CR 7342 also provided guidance to providers to report HCPCS G0010 when billing for the administration of hepatitis B vaccines under the OPPS rather than CPT code 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)) or CPT code 90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)) for services performed beginning January 1, 2011, to ensure the correct waiver of coinsurance and deductible.
B. Policy: Effective for claims processed with dates of service on or after January 1, 2011, OPPS providers report code G0010 for the administration of hepatitis B vaccine.
Guidelines for Reporting Immunization Administration
Codes 90460 and 90461 or 90471–90474 are reported in addition to vaccine/toxoid code(s) 90476– 90749.
• Codes 90460 and 90461 do not differentiate by routes of administration or “first” versus “each additional” administration.
• The age designation for codes 90460 and 90461 (ie, through age 18) is consistent with the age requirements under the federal Vaccines for Children (VFC) program.
• When the physician or qualified health care professional (eg, nonphysicians if allowed under state scope of practice) provides face-to-face counseling for the patient and family during the administration of a vaccine to a patient aged 18 years or younger, code 90460 or a combination of codes 90460 and 90461 are reported. The medical record documentation must support that the physician or other qualified health care professional provided the vaccine counseling.
• Code 90460 is reported for the first component of each vaccine administered whether it is a single or combination vaccine.
• Code 90461 is reported in conjunction with 90460 for each additional component in a given vaccine. The word “component” refers to each antigen in a vaccine that prevents disease(s) caused by one organism. Combination vaccines are those vaccines that contain multiple vaccine components (antigens).
• The immunization administration codes include the provider (ie, physician or other qualified health care professional) work of discussing risks and benefits of the vaccines, providing parents with a copy of the Centers for Disease Control and Prevention (CDC) Vaccine Information Statement (VIS) for each component, the cost of the nursing time to record each component administered in the medical record and statewide vaccine registry, giving the vaccine, observing and addressing reactions or side effects, and the cost of supplies (eg, syringe, needle, bandages).
• When the physician or qualified health care professional does not perform the vaccine counseling to the patient or family, or when vaccines are administered to patients older than 18 years, codes 90471– 90474 are reported instead of codes 90460–90461. Codes 90471–90474 are reported as appropriate based on their current guidelines (ie, either 90471 or 90473 is reported for the first vaccine administered to a patient on a calendar date, and codes 90472 and 90474 are reported for each additional vaccine given on the same date based on its route of administration).
Vaccine Administration Billing Instructions:
• Code the primary vaccine administration code (CPT 90460, 90471, or 90473), the diagnosis code and the EP modifier.
o CPT 90460 should be used to indicate face-to-face counseling was associated with the vaccine administration. CPT 90460 may be billed with more than one unit.
o CPT 90471 and CPT 90473 should be used when there is no face-to-face counseling associated with the vaccine administration. CPT 90471 and CPT 90473 must be billed with a unit value of “1.”
• Code the vaccine product code with the applicable diagnosis code and the EP modifier.
• Code the applicable add-on vaccine administration code (CPT 90472 or 90474) with the appropriate number of units, the diagnosis code and the EP modifier.
o CPT 90472 or CPT 90474 must be coded if more than one non-counseled vaccine was administered.
o CPT 90460 may be used in conjunction with the add-on vaccine administration codes CPT 90472 and CPT 90474 to indicate that first vaccine administered was counseled and the additional vaccines administered were non-counseled.
• Each vaccine administration code should be listed only one time per claim. If multiple vaccine product codes correspond to the same vaccine administration code, the vaccine administration code is listed once with the appropriate number of units indicated.
• The vaccine administration code should be billed with the appropriate charges as outlined in the Department of Community Health Check Services Manual.
A. Background: This change request provides instructions for claims processing and FISS edits to be updated to allow HCPCS code G0010 (Administration of hepatitis B vaccine) to be billed by OPPS providers effective for claims with dates of service on or after January 1, 2011.
In CR 7342, Transmittal 2174, dated March 18, 2011, CMS retroactively assigned HCPCS code G0010 to APC 0436, Level I, Drug Administration, and changed the status indicator for HCPCS code G0010 from status indicator “B” to status indicator “S” effective January 1, 2011.
CR 7342 also provided guidance to providers to report HCPCS G0010 when billing for the administration of hepatitis B vaccines under the OPPS rather than CPT code 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)) or CPT code 90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)) for services performed beginning January 1, 2011, to ensure the correct waiver of coinsurance and deductible.
* NOTE: For claims with dates of service prior to January 1, 2006, OPPS and non-OPPS hospitals report G0010 for hepatitis B vaccine administration. For claims with dates of service January 1, 2006 until December 31, 2010, OPPS hospitals report 90471 or 90472 for hepatitis B vaccine administration as appropriate in place of G0010. Beginning January 1, 2011, providers should report G0010 for billing under the OPPS rather than 90471 or 90472 to ensure the correct waiver of coinsurance and deductible for the administration of hepatitis B vaccine.
Reimbursement Guidelines
Through this policy, UnitedHealthcare Community Plan will ensure compliance with the federally mandated Vaccines For Children program, while reducing inappropriate payments where providers have access to free vaccines for children enrolled in Medicaid, and also meet all State specific requirements. This policy applies to members under age 19 only (age 18 + 364 days).
As part of the Patient Protection and Affordable Care Act (PPACA) regulations the Centers for Medicare & Medicaid Services (CMS) require Medicaid programs to reimburse for Vaccines for Children (VFC) services on administration codes 90460, 90471, 90472, 90473, and/or 90474 rather than the serum/toxoid code. Per the PPACA legislation, CPT code 90461 is NOT reimbursable for VFC services. Some States have determined to pay all of these administration codes (except 90461), some only 90460.
Any variations from this are listed under the State Exceptions portion of this policy. Please refer to the communication posted by your State Fee for Service Medicaid Plan for further details on which administration codes are payable in each State and which immunizations are considered part of the VFC program in each State.
The vaccine code(s) and administration code(s) may be submitted on separate claims, but the claims must be for the same date of service by the same provider and the number of units for each must match.
Excessive units of either code(s) will be denied – i.e. 90658 (vaccine) – 1 unit 90471 (administration) – 1 unit
90696 (vaccine) – 1 unit
90472 (administration) – 2 units – 1 unit would deny as there is no corresponding vaccine code billed
***Administration codes should be billed on one line with multiple units wherever possible to avoid duplicate denials.
Some States require that modifiers be appended to the serum code (s) and/or the vaccine administration code(s). Please refer to the communication posted by your State Fee for Service Medicaid Plan for further details for modifier requirements of each State.
