MA PPO

Reimbursement for the Administration of Immunizations
MA07.019a

Policy

​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.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, reimbursement for the administration of immunizations is covered under the medical benefits of the Company's Medicare Advantage products.

PREVENTIVE VACCINE SERVICES

For information related to preventive vaccine services, refer to the Preventive policy located in the Cross Reference section of this policy.

Description


Immunization (also called vaccination or inoculation) is the process by which an individual is protected against the adverse effects of infection by a disease-causing microorganism by exposure to a small amount of the killed or inactivated organism or pieces of the organism.

Administration is the act of delivering an immunizing agent to an individual by various routes (e.g., intradermal, intramuscular, intranasal, intravenous, oral, percutaneous, or subcutaneous).

References

Centers for Medicare and Medicaid Services (CMS). 2012- 2013 Immunizers’ Question & Answer Guide to Medicare Part B, Medicaid and CHIP Coverage of Seasonal Influenza and Pneumococcal Vaccinations . [CMS Web site.] Available at: http://www.cms.gov/Medicare/Prevention/Immunizations/Downloads/2012-2013_Flu_Guide.pdf

Centers for Medicare and Medicaid Services (CMS). CMS Claims Processing Manual. Chapter 12 - Physicians/Nonphysician Practitioners. [CMS Web site]. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf.

Centers for Medicare and Medicaid Services (CMS). MLN Matters Article. Article # SE1431 Revised. 2010 - 2011 Seasonal Influenza (Flu) Resources for Health Care Professionals2014-2015 Influenza (Flu) Resources for Health Care Professionals. [CMS Web site]. Available at: https://www.cms.gov/MLNMattersArticles/downloads/SE1031.pdf.

Centers for Medicare & Medicaid Services. How to Use the Medicare National Correct Coding Initiative (NCCI) Tools. Available at:http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/How-To-Use-NCCI-Tools.pdf.

Coding

CPT Procedure Code Number(s)
90460, 90461, 90471, 90472, 90473, 90474

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)
G0008 Administration of influenza virus vaccine

G0009 Administration of pneumococcal vaccine

G0010 Administration of hepatitis B vaccine

Revenue Code Number(s)
N/A


Coding and Billing Requirements


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.
  • When an administration of a vaccine Healthcare Common Procedural Coding System (HCPCS) code (G0008, G0009, G0010) is reported by the same physician or other qualified health care professional on the same day of an immunization administration Current Procedural Terminology (CPT) code (90460, 90461, 90471, 90472, 90473, 90474), the appropriate modifier should be applied to indicate that separate and distinct immunizations were administered.

  • Professional providers are eligible to receive separate reimbursement for each component of multiple-antigen immunizations for patients 18 years of age or younger when the professional provider counsels the patient regarding the immunization during the visit in which the immunization is administered.

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 90460 for each additional component of a multiple-antigen immunization.
For example, to report the administration of the MMRV and DTaP immunizations with counseling to a patient 18 years of age or younger, professional providers should report:
  • Codes 90460, 90461, 90461, 90461 for the MMRV immunization
  • Codes 90460, 90461, 90461 for the DTaP immunization

  • To report the administration of a single-antigen or multiple-antigen immunization for pediatric or adult patients 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 a patient without counseling, professional providers should report:
  • Code 90471 for the MMRV immunization
  • Code 90472 for the DTaP immunization

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Policy History

1/1/2016
12/31/2015
MA07.019
Claim Payment Policy Bulletin
Medicare Advantage
Yes