Vaccine/toxoid Reimbursement Changes

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1 Vaccine/toxoid Reimbursement Changes Information posted July 3, 2008 This is an update to a banner message that first appeared on the February 29, 2008, Remittance and Status (R&S) Report about the delayed implementation of changes to the benefit criteria of vaccines/toxoids. Effective for dates of service on or after August 1, 2008, the benefit criteria for vaccines/toxoids will change for Texas Medicaid. Vaccines/toxoids that the Advisory Committee on Immunization Practices (ACIP) identifies as routine or medically necessary are benefits of Texas Medicaid. The administration of these vaccines/toxoids is also a benefit of Texas Medicaid. The administration of vaccines/toxoids to clients who are birth through 20 years of age is a benefit of Texas Health Steps (THSteps) when provided as part of a THSteps periodic visit. A THSteps provider that bills for vaccines/toxoids with diagnosis or age restrictions will continue to be subject to those restrictions. Providers must include on the claim the diagnosis code of the condition necessitating the vaccine/toxoid. The administration of vaccines/toxoids to clients who are birth through 20 years of age is a benefit of the THSteps-Comprehensive Care Program (THSteps-CCP) when provided as part of an acute medical visit outside of a THSteps periodic visit. All providers must assess the immunization status of clients who are birth through 18 years of age at every encounter, or through 20 years of age when part of a THSteps medical checkup. Providers must administer any medically indicated vaccines/toxoids unless medically contraindicated or because of the parent s reason of conscience, including a religious belief. The reason the indicated vaccine/toxoid was not administered must be documented in the client s medical record. The following procedure codes may be used when billing for vaccine/toxoid administration for clients who are birth through 20 years of age: Procedure Codes 1/S /S /S /S /S /S /S /S Only one vaccine administration fee may be reimbursed to any provider for each vaccine/toxoid administered per client, per day. Reimbursement for administration fees requires that the procedure codes for the administered vaccines/toxoids be submitted in addition to the administration fee. Vaccine/toxoid administration fees will be reimbursed based on the number of statedefined components administered per injection. The provider must bill an administration fee without a modifier when a vaccine/toxoid with one state-defined component is administered. A vaccine/toxoid billed without a modifier has a reimbursement rate of $8.00. Facilities are reimbursed a rate of $5.00.

2 The provider must bill an administration fee with state-defined modifier U2 when a vaccine/toxoid with two state-defined components is administered. A vaccine/toxoid billed with modifier U2 has a reimbursement rate of $ Facilities are reimbursed a rate of $7.50. The provider must bill an administration fee with state-defined modifier U3 when a vaccine/toxoid with three state-defined components is administered. The legislation that created the federal Vaccines for Children (VFC) program requires that the Department of Health and Human Services establish a maximum reimbursement limit for the amount a provider can be reimbursed for administrations of vaccines to Texas Vaccines for Children (TVFC)-eligible children. A vaccine/toxoid billed with modifier U3 for a VFC-eligible client has a reimbursement rate of $ A vaccine/toxoid billed with modifier U3 for a client not eligible for VFC has a reimbursement rate of $ Facilities are reimbursed a rate of $ The current federal maximum reimbursement that can be charged for the administration fee for VFC vaccines is $ The following are the descriptions for the U2 and U3 modifiers: Modifier U2 U3 Description State-defined modifier: Administration of vaccine/toxoid with two statedefined components State-defined modifier: Administration of vaccine/toxoid with three statedefined components The following vaccine/toxoid procedure codes are a benefit for clients who are birth through 20 years of age. Procedure Code Number of State- Defined Components 1/S-90632* 1 1/S-90633* 1 1/S /S /S /S /S-90648* 1 1/S-90649* 1 1/S-90655* 1 1/S-90656* 1 1/S-90657* 1 1/S-90658* 1 1/S-90660* 1

3 Procedure Code 1/S-90669* 1 1/S-90680* 1 1/S-90700* 1 1/S-90702* 1 1/S /S /S /S /S-90707* 1 1/S-90710* 2 1/S-90713* 1 1/S-90714* 1 1/S-90715* 2 1/S-90716* 1 1/S /S /S-90723* 3 1/S-90732* 1 1/S /S-90734* 1 1/S /S /S-90744* 1 1/S-90746* 1 1/S /S-90748* 2 1/S Number of State- Defined Components * Indicates a vaccine/toxoid distributed through TVFC Vaccines/toxoids may be reimbursed through THSteps with modifier U1 when the vaccine/toxoid is not available for distribution through TVFC. Vaccines/toxoids may be reimbursed as part of a THSteps periodic visit or as part of an acute medical visit (through THSteps-CCP). Not available is defined as: a new vaccine approved by the ACIP that has not been negotiated or added to a TVFC contract; TVFC has not established funding for a new vaccine; or national supply or distribution issues limit availability.

4 Vaccines/toxoids may be reimbursed through THSteps-CCP with modifier U1 when the provider purchases a vaccine/toxoid for an ACIP-recommended age or cohort administered outside of the TVFC age or cohort. Modifier U1 may not be used for failure to enroll in TVFC or to maintain sufficient TVFC vaccine/toxoid inventory. The description for the U1 modifier is State-defined modifier: Vaccines/toxoids privately purchased by provider when TVFC vaccine/toxoid is not available. Single- or multiple-antigen vaccines/toxoids that are comparable to vaccines/toxoids available for distribution through TVFC will not be covered when the provider chooses to use a different ACIP-recommended product; however, the administration fee may be reimbursed. Vaccines/toxoids available through TVFC for clients who are birth through 18 years of age will not be reimbursed by Texas Medicaid. These vaccines/toxoids will be processed as informational details. Providers may need to bill the vaccine for $.01 so that the claim can be processed but may not otherwise charge Medicaid for the vaccine obtained from TVFC. When the vaccine is available through TVFC, reimbursement for vaccines/toxoids administered to clients who are birth through 18 years of age will be denied even if the provider is not enrolled in TVFC. Providers must not bill the client for vaccines/toxoids available through TVFC. The administration fee may be reimbursed through Texas Medicaid when the vaccine/toxoid is identified by procedure code on the claim. The specific diagnosis code of the condition necessitating the vaccine/toxoid is required when billing with the administration fee in combination with the appropriate vaccine procedure code. For clients who are birth through 20 years of age, diagnosis code V202 (routine infant or routine child health check) may be used unless there is a more specific diagnosis code. Additional age-based reimbursement limitations: For clients who are birth through 18 years of age: The state-mandated administration of the hepatitis B vaccine to newborns before discharge from the hospital has been established as the accepted standard of care and will not be considered as a reason to upgrade to a different diagnosis-related group (DRG). The administration of the hepatitis B vaccine to newborns is included in the DRG payment and will not be reimbursed separately. For clients who are 21 years of age or older: Administration of vaccines/toxoids for clients 21 years of age and older is a benefit when the vaccine is medically necessary. Procedure codes , , , and may be used when billing for vaccine/toxoid administration for clients 21 years of age and older: The following vaccine/toxoid procedure codes are benefits for clients who are 21 years of age and older:

5 Procedure Code * *Only for female clients 21 years of age and older Only one vaccine administration fee may be reimbursed to any provider for each vaccine/toxoid administered per client, per day. Modifiers U1, U2, and U3 do not apply when submitting claims for the vaccine administration and vaccine toxoids. The administration fee may be reimbursed through Texas Medicaid when the vaccine/toxoid is identified by procedure code on the claim. The specific diagnosis code of the condition necessitating the vaccine/toxoid is required when billing with the administration fee in combination with the appropriate vaccine procedure code. For all clients: Providers must document the following information in the client s medical record: The vaccine/toxoid given. The date of the vaccine/toxoid administration (day, month, year). The name of the vaccine/toxoid manufacturer and the lot number. The signature and title of the person administering the vaccine/toxoid. The organization name and address of the clinic location. The publication date of the vaccine information statement issued to the client, parent, or guardian. The client s medical records are subject to retrospective review to determine appropriate utilization and reimbursement of this service. The National Childhood Vaccine Injury Act requires health-care providers to report the following: Any reaction listed by the vaccine manufacturer as a contraindication to subsequent doses of the vaccine. Any reaction listed in the Reportable Events Table that occurs within the specified time period after vaccination. Clinically significant adverse events should be reported even if it is unclear whether a vaccine caused the event. A copy of the Reportable Events Table can be obtained by calling the Vaccine Adverse Event Recording System (VAERS) at or by downloading it from Documentation of the injection site is recommended but not required. For more information, call the TMHP Contact Center at