CHILDHOOD IMMUNIZATIONS APPLICATIONS OBJECTIVE Purpose of Measure: ELIGIBLE POPULATION Which members are included? STANDARD OF CARE What immunizations should be administered? NCQA ACCEPTED CODES DOCUMENTATION REQUIREMENTS What documentation should be submitted? HEDIS (Hybrid) NCQA Accreditation NCQA Rating EPSDT* To identify children due for an immunization Children who turn two (2) years of age as of December 31st of the measurement year. By their second (2 nd ) birthday, children should receive all of the following: 4 diptheria, tetanus, and acellular pertussis (DTaP) 3 polio (IVP) 1 measles, mumps, and rubella (MMR) 3 H influenza type B (HiB) 3 hepatitis B (Hep B) 1 chicken pox (VZV) 4 pneumococcal conjugate (PCV) 1 hepatitis A (Hep A) 2 or 3 rotavirus (RV) 2 influenza (flu) Note: The member must have all of the recommended doses of each vaccine prior to their second birthday in order to be compliant with HEDIS. Rates are calculated on individual vaccines and in combinations as outlined in NCQA s HEDIS Technical Specifications. Please see code table. For each immunization given: A note indicating the name of the immunization and date given, or A certificate of immunization prepared by an authorized health care provider or agency that includes the type of immunization and date administered. State immunization certificates should be
signed and dated. For Hepatitis B, notations that the first dose was administered at birth or in the hospital are acceptable. For Rotavirus, the documentation should indicate whether the two- or three-dose schedule was administered. If the documentation does not clearly indicate if the two-or three-dose vaccine was given, it will be assumed the three-dose was used. Flumist is not acceptable for either dose of the required influenza vaccines. Documentation of parental refusal of vaccines(s) is not compliant under HEDIS specifications. REFERENCES For each immunization not given: Documentation of a contraindication to the vaccine or its components, (such as anaphylactic reaction). DTaP: diagnosis of encephalopathy IVP: anaphylactic reaction to streptomycin, polymyxin B, or neomycin MMR, VZV, and influenza: immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, leukemia, or anaphylactic reaction to neomycin Hepatitis B: anaphylactic reaction to common baker s yeast A documented history of the illness or a seropositive test result. Note must indicate date of the event, which must have occurred prior to the member s second (2 nd ) birthday. For more information, please refer to Passport Health Plan s Preventive Health Clinical Practice Guideline including current immunization schedules, KY EPSDT Manual, and the AAP Bright Futures Provider Toolkit.
The criteria above are based on standards established under NCQA s HEDIS 2016 Technical Specifications. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). *The Early and Periodic Screening Diagnosis and Treatment (EPSDT) program is designed to provide a comprehensive preventive health care package to members from birth to age 21. For billing and or other questions/concerns please contact your Provider Network Account Manager or Provider Services at (800)-578-0775.
DTaP Code System Code CPT 90698 CPT 90700 CPT 90721 CPT 90723 Inactivated Polio Vaccine (IPV) Code System Code CPT 90698 CPT 90713 CPT 90723 MMR Code System Code Measles, Mumps and Rubella Vaccine CPT 90707 CPT 90710 Measles/Rubella Vaccine CPT 90708 Measles Vaccine CPT 90705 Mumps Vaccine CPT 90704 Rubella Vaccine CPT 90706 CHILDHOOD IMMUNIZATION STATUS Meet Screening Criteria Measles ICD10CM B05.0 [B05.0] Measles complicated by encephalitis ICD10CM B05.1 [B05.1] Measles complicated by meningitis ICD10CM B05.2 [B05.2] Measles complicated by pneumonia ICD10CM B05.3 [B05.3] Measles complicated by otitis media ICD10CM B05.4 [B05.4] Measles with intestinal complications ICD10CM B05.81 [B05.81] Measles keratitis and keratoconjunctivitis ICD10CM B05.89 [B05.89] Other measles complications ICD10CM B05.9 [B05.9] Measles without complication ICD9CM 055.0 Postmeasles encephalitis ICD9CM 055.1 Postmeasles pneumonia ICD9CM 055.2 Postmeasles otitis media ICD9CM 055.71 Measles keratoconjunctivitis ICD9CM 055.79 Measles with other specified complications
ICD9CM 055.8 Measles with unspecified complication ICD9CM 055.9 Measles without mention of complication Mumps ICD10CM B26.0 [B26.0] Mumps orchitis ICD10CM B26.1 [B26.1] Mumps meningitis ICD10CM B26.2 [B26.2] Mumps encephalitis ICD10CM B26.3 [B26.3] Mumps pancreatitis ICD10CM B26.81 [B26.81] Mumps hepatitis ICD10CM B26.82 [B26.82] Mumps myocarditis ICD10CM B26.83 [B26.83] Mumps nephritis ICD10CM B26.84 [B26.84] Mumps polyneuropathy ICD10CM B26.85 [B26.85] Mumps arthritis ICD10CM B26.89 [B26.89] Other mumps complications ICD10CM B26.9 [B26.9] Mumps without complication ICD9CM 072.0 Mumps orchitis ICD9CM 072.1 Mumps meningitis ICD9CM 072.2 Mumps encephalitis ICD9CM 072.3 Mumps pancreatitis ICD9CM 072.71 Mumps hepatitis ICD9CM 072.72 Mumps polyneuropathy ICD9CM 072.79 Other mumps with other specified complications ICD9CM 072.8 Mumps with unspecified complication ICD9CM 072.9 Mumps without mention of complication Rubella ICD10CM B06.00 [B06.00] Rubella with neurological complication, unspecified ICD10CM B06.01 [B06.01] Rubella encephalitis ICD10CM B06.02 [B06.02] Rubella meningitis ICD10CM B06.09 [B06.09] Other neurological complications of rubella ICD10CM B06.81 [B06.81] Rubella pneumonia ICD10CM B06.82 [B06.82] Rubella arthritis ICD10CM B06.89 [B06.89] Other rubella complications ICD10CM B06.9 [B06.9] Rubella without complication ICD9CM 056.00 Rubella with unspecified neurological complication ICD9CM 056.01 Encephalomyelitis due to rubella ICD9CM 056.09 Rubella with other neurological complications ICD9CM 056.71 Arthritis due to rubella ICD9CM 056.79 Rubella with other specified complications ICD9CM 056.8 Rubella with unspecified complications ICD9CM 056.9 Rubella without mention of complication HiB Code System Code CPT 90645 CPT 90646
CPT 90647 CPT 90648 CPT 90698 CPT 90721 CPT 90748 CPT 90698 Hepatitis B CPT 90723 CPT 90740 CPT 90744 CPT 90747 CPT 90748 HCPCS G0010 Administration of hepatitis b vaccine (G0010) ICD10PCS 3E0234Z [3E0234Z] Introduction of Serum, Toxoid and Vaccine into Muscle, Percutaneous Approach ICD9PCS 99.55 Prophylactic administration of vaccine against other diseases ICD10CM B16.0 [B16.0] Acute hepatitis B with delta-agent with hepatic coma ICD10CM B16.1 [B16.1] Acute hepatitis B with delta-agent without hepatic coma ICD10CM B16.2 [B16.2] Acute hepatitis B without delta-agent with hepatic coma ICD10CM B16.9 [B16.9] Acute hepatitis B without delta-agent and without hepatic coma ICD10CM B17.0 [B17.0] Acute delta-(super) infection of hepatitis B carrier ICD10CM B18.0 [B18.0] Chronic viral hepatitis B with delta-agent ICD10CM B18.1 [B18.1] Chronic viral hepatitis B without delta-agent ICD10CM B19.10 [B19.10] Unspecified viral hepatitis B without hepatic coma ICD10CM B19.11 [B19.11] Unspecified viral hepatitis B with hepatic coma ICD10CM Z22.51 [Z22.51] Carrier of viral hepatitis B ICD9CM 070.20 Viral hepatitis B with hepatic coma, acute or unspecified, without mention of hepatitis delta ICD9CM 070.21 Viral hepatitis B with hepatic coma, acute or unspecified, with hepatitis delta ICD9CM 070.22 Chronic viral hepatitis B with hepatic coma without hepatitis delta ICD9CM 070.23 Chronic viral hepatitis B with hepatic coma with hepatitis delta ICD9CM 070.30 Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta ICD9CM 070.31 Viral hepatitis B without mention of hepatic coma, acute or unspecified, with hepatitis delta ICD9CM 070.32 Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta ICD9CM 070.33 Chronic viral hepatitis B without mention of hepatic coma with hepatitis delta ICD9CM V02.61 Hepatitis B carrier Varicella Zoster (VZV) CPT 90710 CPT 90716
ICD10CM B01.0 [B01.0] Varicella meningitis ICD10CM B01.11 [B01.11] Varicella encephalitis and encephalomyelitis ICD10CM B01.12 [B01.12] Varicella myelitis ICD10CM B01.2 [B01.2] Varicella pneumonia ICD10CM B01.81 [B01.81] Varicella keratitis ICD10CM B01.89 [B01.89] Other varicella complications ICD10CM B01.9 [B01.9] Varicella without complication ICD10CM B02.0 [B02.0] Zoster encephalitis ICD10CM B02.1 [B02.1] Zoster meningitis ICD10CM B02.21 [B02.21] Postherpetic geniculate ganglionitis ICD10CM B02.22 [B02.22] Postherpetic trigeminal neuralgia ICD10CM B02.23 [B02.23] Postherpetic polyneuropathy ICD10CM B02.24 [B02.24] Postherpetic myelitis ICD10CM B02.29 [B02.29] Other postherpetic nervous system involvement ICD10CM B02.30 [B02.30] Zoster ocular disease, unspecified ICD10CM B02.31 [B02.31] Zoster conjunctivitis ICD10CM B02.32 [B02.32] Zoster iridocyclitis ICD10CM B02.33 [B02.33] Zoster keratitis ICD10CM B02.34 [B02.34] Zoster scleritis ICD10CM B02.39 [B02.39] Other herpes zoster eye disease ICD10CM B02.7 [B02.7] Disseminated zoster ICD10CM B02.8 [B02.8] Zoster with other complications ICD10CM B02.9 [B02.9] Zoster without complications ICD9CM 052.0 Postvaricella encephalitis ICD9CM 052.1 Varicella (hemorrhagic) pneumonitis ICD9CM 052.2 Postvaricella myelitis ICD9CM 052.7 Chickenpox with other specified complications ICD9CM 052.8 Chickenpox with unspecified complication ICD9CM 052.9 Varicella without mention of complication ICD9CM 053.0 Herpes zoster with meningitis ICD9CM 053.10 Herpes zoster with unspecified nervous system complication ICD9CM 053.11 Geniculate herpes zoster ICD9CM 053.12 Postherpetic trigeminal neuralgia ICD9CM 053.13 Postherpetic polyneuropathy ICD9CM 053.14 Herpes zoster myelitis ICD9CM 053.19 Herpes zoster with other nervous system complications ICD9CM 053.20 Herpes zoster dermatitis of eyelid ICD9CM 053.21 Herpes zoster keratoconjunctivitis ICD9CM 053.22 Herpes zoster iridocyclitis ICD9CM 053.29 Herpes zoster with other ophthalmic complications ICD9CM 053.71 Otitis externa due to herpes zoster ICD9CM 053.79 Herpes zoster with other specified complications ICD9CM 053.8 Herpes zoster with unspecified complication
ICD9CM 053.9 Herpes zoster without mention of complication Pneumococcal Conjugate CPT 90669 CPT 90670 HCPCS G0009 Administration of pneumococcal vaccine (G0009) Hepatitis A CPT 90633 ICD10CM B15.0 [B15.0] Hepatitis A with hepatic coma ICD10CM B15.9 [B15.9] Hepatitis A without hepatic coma ICD9CM 070.0 Viral hepatitis A with hepatic coma ICD9CM 070.1 Viral hepatitis A without mention of hepatic coma Rotavirus CPT 90681 2 Dose Schedule CPT 90680 3 Dose Schedule Influenza CPT 90655 CPT 90657 CPT 90661 CPT 90662 CPT 90673 CPT 90685 HCPCS G0008 Administration of influenza virus vaccine (G0008) Exclusions Any Particular Vaccine Anaphylactic reaction to the vaccine or its components DTaP Encephalopathy with a vaccine adverse-effect code MMR, VZV and Influenza Immunodeficiency HIV Lymphoreticular cancer, multiple myeloma or leukemia Anaphylactic reaction to neomycin IPV Anaphylactic reaction to streptomycin, polymyxin B or neomycin Hepatitis B Anaphylactic reaction to common baker s yeast