CPT CODE and description
90686 – Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use –
90715 – Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular us
Tdap Tetanus -Diphtheria -Pertussis Boostrix SKB Pedi: 1 dose at 11-12 years; Catch-up vaccination < 19 yrs; during each pregnancy 0.5 mL IM 90715 115 Free Adacel PMC Adult: 1 dose for unvaccinated adults >19 years ; vaccinate pregnant5 women during each pregnancy; Varicella Chickenpox Varivax MSD Pedi & Adult: 1 st dose at 12-15 months; catch-up vaccination
children and adults 19- 26 years 0.5 mL SC 90716 21 Free
DT & Tdap/Td Administration of influenza virus vaccine Varicella virus vaccine (VAR), live, for subcutaneous use (Varivax) Influenza Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use Tetanus, diphtheria toxoids and acellular pertussis (Tdap), when administered to individuals 7 years or older, for intramuscular use
Background
This recurring update notification provides the payment allowances for the following seasonal infl uenza virus vaccines, when payment is based on 95 percent of the Average Wholesale Price (AWP).
The Medicare Part B payment allowances for the following Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes below apply for the effective dates of August 1, 2015 July 31, 2016:
• CPT 90655 Payment allowance is pending;
• CPT 90656 Payment allowance is pending;
• CPT 90657 Payment allowance is pending;
• CPT 90661 Payment allowance is pending;
• CPT 90685 Payment allowance is pending;
• CPT 90686 Payment allowance is pending;
• CPT 90687 Payment allowance is pending;
• CPT 90688 Payment allowance is pending;
• HCPCS Q2035 Payment allowance is pending;
• HCPCS Q2036 Payment allowance is pending;
• HCPCS Q2037 Payment allowance is pending; and
• HCPCS Q2038 Payment allowance is pending.
Submit claims for shingles or tetanus vaccinations to Medicare Part D
Providers who have administered a shingles (90736; regardless of any diagnosis) or tetanus vaccine (90714, 90715, 90718 & 90723; regardless of any diagnosis) to our individual and group-sponsored Medicare Advantage plan members with pharmacy benefits should bill the Medicare Part D Benefit. Providers will encounter a denial if these claims are billed to the Medical benefit because the claim is covered under Medicare Part D only. This applies to the vaccine and the administration charges. Please note you can refer your patients to their local pharmacy for administration as well.
For Medicare Part B benefit of tetanus vaccine (90703; diagnosis range 800.00 to 897.99), this may be submitted as a medical claim for processing.
A given service or procedure billed to the Medicare program may not be linked to a National Coverage Determination (NCD) or Local Coverage Determination (LCD). Assuming all other requirements of the program are met and absent specific coverage criteria outlined in a LCD or NCD, all procedures or services must meet the medically reasonable and necessary threshold for coverage as demonstrated by the performing provider or attending physician in the official medical record. The Noncovered Services LCD compiles services or procedures that have been addressed by the Medical Policy department as to the medically reasonable and necessary threshold for coverage. Certain services or procedures will not have specific level I or level II HCPCS coding. Such services or procedures would be coded as the appropriate unclassified code. Occasionally services or procedures will be identified by a specific level I (Category I or Category III CPT code) or level II HCPCS code. It is the expectation that physicians and allied providers code to specificity. Payment of a claim is not a coverage statement especially if payable codes were used to bypass the medical review of more specific Level I/Category I unlisted codes or Level I/Category III codes or level II HCPCS codes.
In determining if a service or procedure reaches the threshold for coverage, this contractor addresses the quality of the evidence per the program integrity manual in making its recommendation to non-cover a service, pending new information in the public domain. This recommendation is taken through the LCD development process (draft recommendation of noncoverage, 45-day comment period, CAC advisory meeting, open public meeting, finalization, and 45-day notice period). Any interested stakeholder can request a reconsideration of an LCD after the notice period. In the case of the Noncovered Services LCD the stakeholder will receive a list of the articles and related information in the public domain that were addressed by the Medical Policy department in making the noncoverage decision. If the stakeholder has new information based on the evaluation of the list, a LCD reconsideration can be initiated. It is the responsibility of the interested stakeholder to request the evidentiary list from the contractor and to submit the additional articles, data, and related information in support of their request for coverage. The request must meet the LCD reconsideration requirements outlined on the web site.
It is not unusual that there will be a paucity of information for an emerging technology or service, and the Medial Policy department may noncover a service as noted in this LCD awaiting information in the public domain on safety and efficacy based on the quality of evidence. Also this contractor may be silent in terms of LCD in regard to a service or procedure (such a procedure or service is not listed in the Noncovered Services LCD or has been removed from the Noncovered Services LCD). A service or procedure not addressed in the Noncovered Services LCD is not a positive coverage statement. Claims for such services assuming all other requirements of the program are met would always need to meet the medically reasonable and necessary threshold for coverage in a prepayment or post payment audit of the official medical record.
Vaccine administration – State Exceptions policy
Arizona The SL modifier must be appended to the vaccine administration code and the serum code. If the SL modifier is not appended, both the administration and serum codes will be denied. Per State Regulations, the serum code should be billed with a $0.00 charge. California Per State Regulations-
* California requires the SL modifier be appended to the vaccine serum code. If the SL modifier is not appended, the serum code will not be counted and the corresponding administration code will be denied.
* California will only reimburse administration code 90471 for VFC related vaccines. Exception: serum code 90723 must be billed with admin code 90460.
* Code 90644 needs to be billed with an SK modifier or SK and SL but not SL alone
* Code 90734 needs to be billed with modifiers SK and SL for children 0 to 10 but only with the SL modifier for children 11 to 18 Florida The Florida Healthy Kids product does not participate in the VFC program. Hawaii Hawaii’s VFC program services members through age 20. Kansas Kansas Medicaid claims submitted with modifier SL will be denied unless the federal government has announced a vaccine shortage through the VFC program.
Maryland Maryland requires the SE modifier to be appended to the vaccine serum code effective with dates of service as of 9/1/13. If the modifier is not appended with dates of service on or after 9/1/13, the serum code will be denied. Per State Regulation, Maryland pays on the serum code rather than the vaccine administration code. The administration code is not required to be on the claim.
Massachusetts Massachusetts Senior Care Options (SCO) Plan is for individuals who are 65 and over and they do not enroll any children. The VFC program does not apply to Massachusetts. Mississippi The EP modifier must be appended to the vaccine administration code and the serum code. If the EP modifier is not appended, both the administration and serum codes will be denied.
CPT 90715 may be billed without the EP modifier for pregnant patients under 19 years of age.
Missouri Missouri requires the SL modifier be appended to the vaccine serum code. If the SL modifier is not appended, the serum code will be denied. Per State Regulation, Missouri pays on the serum code rather than the vaccine administration code. The administration code is not required to be on the claim. Missouri CHIP members should not be excluded from VFC Nebraska Nebraska requires the SL modifier be appended to the vaccine serum code. If the SL modifier is not appended, the serum code will be denied. Per State Regulation, Nebraska pays on the serum code rather than the vaccine administration code. The administration code is not required to be on the claim. Nebraska’s SCHIP product does not participate in the VFC program. New Jersey Medicaid members in New Jersey’s FamilyCare Plans B, C, and D are excluded from this policy.
New Mexico Administration code 90461 is covered for VFC related vaccines. New York New York requires the SL modifier be appended to the vaccine serum code. If the SL modifier is not appended, the serum code will not be counted and the corresponding administration code will be denied.
New York will only reimburse administration code 90460 for VFC related vaccines. Ohio The Ohio Department of Medicaid developed a uniform pediatric vaccine billing policy and practice that will be implemented in both Medicaid Fee for Service and all the Managed Care Plans (MCPs). Medicaid FFS- and MCP-contracted providers shall adhere to the following instructions when coding and submitting claims for pediatric vaccines administered to Medicaid recipients: Use CPT code 90460 for the administration of vaccines administered under the federal vaccines for children (VFC) program. CPT code 90461 should not be used for the reporting of each vaccine toxoid component of a combination vaccine since as previously noted above ODM will pay providers for each separate vaccine administration. Additionally, vaccine administration codes 90471 through 90474 should not be used for the administration of vaccines covered under the federal VFC program (since ODM applies a $15.00 payment for each vaccine being administered).
Report CPT code 90460 on each claim along with each vaccine toxoid CPT code administered. 90460 should be reported on multiple detail lines to indicate the total number of administrations performed. Total number of detail lines reported must equal total number of VFC vaccine toxoid codes administered by the provider. Submit a charge of $0.00 with the toxoid code to Medicaid MCPs and fee-for-service in order for the claims payment system to accurately process these claims. Report the appropriate vaccine toxoid CPT code for the administration of combination vaccines.
Separate payment for either an office visit or well child visit will be allowed as long as the provider’s documentation supports that a separately identifiable visit was performed in addition to the administration of vaccines. Providers will need to append the visit code with modifier 25 to signify that a separately identifiable visit was provided. Pennsylvania Pennsylvania’s CHIP product does not participate in the VFC program. Rhode Island The serum code is not required to be on the claim.
Effective 5/1/2016, administration code 90461 is covered for VFC related vaccines. Texas Administration code 90461 is covered for VFC related vaccines. TX providers are required to bill multiple duplicate admin codes on a single claim. Washington Washington state requires the SL modifier be appended to the vaccine serum code. If the SL modifier is not appended, the serum code will be denied. Per State Regulation, Washington pays on the serum code rather than the vaccine administration code. The administration code is not required to be on the claim.
Vaccine Type CVX CPT
Effective January 1, 2017, redefined CPT codes 90656, 90657, 90658, 90685, 90686, 90687, and 90688 will reflect dosage amounts, in lieu of age indications.
1. Influenza IIV3 (inject) (multi-dose vials) 141 90658 (4 yrs & older)1
2. Influenza IIV3 (P-Free, Inj) (prefilled syringe) 140 90656 (4 yrs & older)
3. Influenza IIV3 (Fluad, P-Free, Inj) (prefilled syringe) 168 90653 (65 yrs & older)
4. Influenza IIV3 High-Dose (prefilled syringe) 135 90662 (65 yrs & older)
5. Influenza LAIV4 (FluMist)* (prefilled nasal spray) 149 90672 (2-49yrs)
*LAIV4 (FluMist) is not recommended by the Advisory Committee on Immunization Practices (ACIP) for use during the 2016-2017 influenza season in the United States and is not a VFC vaccine option.
6. Influenza IIV4 (inject) (multi-dose vials) 158 90687 (6-35 months) 90688 (3 yrs & older)
7. Influenza IIV4 Ped (P-Free, Inj) (prefilled syringe) 161 90685 (6-35 months)
8. Influenza IIV4 (P-Free, Inj) (prefilled syringe and single-dose vials) 150 90686 (3 yrs & older)
9. Influenza IIV4 Intradermal (P-Free, Inj) (prefilled syringe) 166 90630 (18-64 yrs)
10. Influenza RIV3 (Flublok, P-Free) (single-dose vials) 155 90673 (18 yrs & older)
11. Influenza ccIIV4 (Flucelvax, P-Free, Inj) (prefilled syringe) 90674 (4 yrs & older)
Seasonal Influenza Virus Vaccine Administration Code:
G0008 Diagnosis Code: Z23
90630 – Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use
90653 – Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use
90654 – Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use
90655 – Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use
90656 – Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use
90657 – Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use
90660 – Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use
90661 – Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
90662 – Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
90672 – Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use
90673 – Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use
90674 – Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
90685 – Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use
90686 – Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use
90687 – Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use
90688 – Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use
Q2035 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
Q2036 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
Q2037 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
Q2038 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
Q2039 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified)
