The administration of immunizations is covered and eligible for reimbursement by the Company when the specific immunization agent is covered.
Primary care providers (PCPs) who receive a monthly capitation fee are reimbursed in addition to capitation for the administration of immunizations.
When more than one immunization is administered on the same date of service, each administration procedure is eligible for separate reimbursement consideration.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
BILLING REQUIREMENTS
Based on National Correct Coding Initiative (NCCI), reimbursement of both the evaluation and management (E&M) service and the immunization administration is contingent upon the provider reporting the modifier 25. Modifier 25 is used to identify a significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service. Documentation to substantiate the use of the modifier should be in the member's medical record and available for review if requested. Current Procedural Terminology (CPT) codes 90460 and 90461 are only reported when the professional provider or qualified health care professional provides face-to-face counseling of the individual and/or the individual's family during the administration of a vaccine. For immunization administration of any vaccine that is not accompanied with face-to-face counseling by a professional provider or qualified health care professional, report CPT codes 90471-90474.Professional providers are eligible to receive separate reimbursement for the administration of each component of multiple-antigen immunizations for individuals 18 years of age or younger when the professional provider counsels the individual regarding the immunization during the visit in which the immunization is administered (CPT codes 90460 and 90461). In this instance, professional providers should report CPT code 90460 for the first component of each immunization administered. CPT code 90461 should be reported in addition to CPT code 90460 for each additional component of a multiple-antigen immunization.
For example, to report the administration of the Measles, mumps, rubella, and varicella (MMRV) and the diphtheria, tetanus, and acellular pertussis (DTaP) immunizations with counseling to an individual 18 years of age or younger, professional providers should report:
- CPT codes 90460, 90461, 90461, 90461 for the MMRV immunization
- CPT codes 90460, 90461, 90461 for the DTaP immunization
To report the administration of a single-antigen or multiple-antigen immunization for pediatric or adult individuals without counseling, professional providers should report CPT codes 90471 or 90473 for the first immunization, and 90472 or 90474 for each additional immunization.
For example, to report the intradermal administration of the MMRV and DTaP immunizations to an individual without counseling, professional providers should report:
- CPT code 90471 for the MMRV immunization
- CPT code 90472 for the DTaP immunization
Counseling by a physician or other qualified health care professional at the time of the immunization administration is critical and a requirement of CPT codes 90460 and 90461. The medical record documentation should support the time and effort associated with administering combination vaccines. If counseling is provided for some, but not all, vaccine/toxoid components to be administered, CPT codes 90460-90461 and CPT codes 90471-90474 may be reported together to accurately reflect the services rendered.
For example, if counseling is performed for human papillomavirus (HPV) vaccine but not for an influenza vaccine provided at the same visit, professional providers should report codes 90460 (with counseling) for the HPV and 90472 (non-counseled) for the influenza vaccine.
Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
