Immunization Guidelines

Description

Immunization is the process of protecting susceptible individuals from communicable diseases by administration of a living modified agent, a suspension of killed organisms, or an inactivated toxin. Immunization is accomplished through various techniques, most commonly by vaccination. Vaccines against microorganisms that cause disease prepares the body’s immune system to enable it to fight off or prevent infection.

Policy

Immunization services are allowed in accordance with the Preventive Care Guidelines found on the Blue Cross Blue Shield North Carolina (Blue Cross NC) internet site (www.bcbsnc.com) and the member’s certificate benefits.

Reimbursement Guidelines

Immunizations are reimbursed when the member certificate of coverage includes benefits for immunizations.

Unless specifically excluded by a member’s contract, Blue Cross NC will allow reimbursement for new vaccines formally recommended by Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC).

Rationale

If a significantly separately identifiable evaluation and management service is provided at the time of vaccine administration, the evaluation and management service should be reported in addition to the vaccine and toxoid procedure.

Separate reimbursement will be allowed for preventive medicine services 99381-99397.

Separate reimbursement will be allowed for the administration of the vaccine for codes (90460-90474, G0008- G0010). 

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Codes G0008-G0010, 90460 and 90461 must be reported in addition to the vaccine and toxoid codes 90476- 90759 or Q2034-Q2039. Report codes 90460-90461 only when the physician or qualified health care professional provides face-to-face counseling of the patient and family during the administration of a vaccine. Counseling related to administered vaccines is incidental to the administration codes (G0008-G0010, 90460- 90461).

For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family for administration of vaccines to patients over 18 years of age, report codes 90471-90474.

Codes 90476-90759 identify the vaccine product only. To report the administration of a vaccine/toxoid, the vaccine product code must be used in addition to the administration code 90460-90474. Modifier 51 should not be reported for the vaccines/toxoids when performed with these administration procedures.

Each immunization given must be filed on a single line of the CMS 1500 claim form, with its specific CPT® code.

Modifier 25 must be used with all evaluation and management services when reporting a significant, separately identifiable service in addition to the immunization services.

It is inappropriate to use the unlisted vaccine code CPT 90749 to report immunization administration services.

The invoice from the laboratory or pharmacy the vaccine has been purchased from may be requested for claim review.

ZOSTAVAX® (Zoster Vaccine Live) and SHINGRIX (Zoster Vaccine Recombinant, Adjuvanted) have FDA approval for use in prevention of herpes zoster (shingles): in individuals 50 years of age and older as well as in individuals aged 19 years and older who are or will be at increased risk due to immunodeficiency or immunosuppression caused by known disease or therapy.

NOTE: Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.

State-Supplied Vaccines

Modifier 52 is not recognized with vaccine immunization codes to represent vaccines that are state supplied.

BCBSNC HMO, POS, PPO and CMM Products:

If the administered drug or substance was not supplied by the professional provider, the drug or substance service line should still be attached to the claim with a $.01 charge.

Submit state-supplied vaccines with the immunization product code affixed with the Modifier SL.

Blue Card Host and FEP Products:

Submit state-supplied vaccines with the immunization product code affixed with the Modifier SL.

Related policy

Bundling Guidelines

References

Medical Policy Advisory Group - 9/2001

Medical Policy Advisory Group - 10/2003

Medical Policy Advisory Group - 03/10/2005

Medical Policy Advisory Group - 03/24/2006

Medical Director review – 9/2011

Medical Director review – 3/2013

Use of Recombinant Zoster Vaccine in Immunocompromised Adults Aged ≥19 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022 | MMWR (cdc.gov)

Provider_FAQs_Vaccine_12.8.20_vFINAL_4.15.21 Update.pdf

History

1/00 Implementation

3/00 Removed reference to Blue Edge

4/01 Reference to archived medical policy Preventive Health Services changed to the Preventive Care Guidelines on the website. Policy reformatted.

6/01 Code range added to coding section.

9/01 Medical Policy Advisory Group review. No change to policy.

10/03 Biannual review of policy completed. Medical Policy Advisory Group review. Reformatted to provide additional information on immunizations.

1/06/05 These are the first quarter 2005 CPT codes: 90465, 90466, 90467, 90468 and 90656. Removed references to Medpoint and PCP as they no longer are applicable to this policy.

04/07/05 Medical Policy Advisory Group reviewed policy on 03/10/2005. Changed the code range to include the first quarter codes.

7/7/05 New code 90714 effective 07/01/2005.

5/08/06 Medical Policy Advisory Group review 3/24/06. No change to policy criteria. Policy number added to the Key Words Section.

9/10/07 Revised the wording in the “Billing/Coding/Physician Documentation” section to coincide with the Provider Bluebook language. Medical Policy reviewed by Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy.

12/3/07 Under the section titled, “Claim Review of Immunization Services “, added Unless specifically excluded by a member’s contract BCBSNC will allow coverage for new vaccines formally recommended by any of the following: the U.S. Preventative Services Task Force; the American Academy of Pediatrics; and the Advisory Committee on Immunization Practices. “Under the section titled, “Policy Guidelines” added “Separate reimbursement will be allowed for the administration of the vaccines codes (90465 - 90474).

10/06/08 Removed the following, “Participating Primary Care Physicians are encouraged to participate in the State of North Carolina Immunization Program, which reimburses serum cost for specific immunizations.” from the Policy Guidelines. Policy reviewed 09/10/2008, by Vice President and Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy.

6/22/10 Policy Number(s) removed (amw)

1/4/11 Added new CPT codes 90460, 90461, 90654. Added new HCPCS codes Q2035- Q2039. (lpr)

10/25/11 Revised description. Added the following codes to the Billing/Coding section: G0008, G0009, G0010, G9141, G9142. Information regarding appropriate coding of administration of vaccines also added to Billing/Coding section. (adn)

6/12/12 Added code Q2034 to the code range in the Billing/Coding section for the July 1, 2012 update. (adn)

2/26/13 Codes G9141 and G9142 deleted. (adn)

4/1/13 ZOSTAVAX® (Zoster Vaccine Live), has FDA approval for use in prevention of herpes zoster (shingles) in individuals 50 years of age and older. (adn)

5/13/14 Policy category changed from “Corporate Medical Policy” to “Corporate Reimbursement Policy”. No changes to policy content. (adn)

9/1/15 Information added to Coding/Billing section regarding ICD-10 coding for rabies vaccinations. Revised the range of vaccine administration codes to 90460-90474. (adn)

12/30/16 Updated Billing/Coding section to include new code 90750. No change to policy statement. (an)

12/29/17 Routine review. Updated Billing/Coding section to include new code 90756. No change to policy statement. (an)

6/8/18 Added SHINGRIX (Zoster Vaccine Recombinant, Adjuvanted) to Billing/Coding section. SHINGRIX has FDA approval for treatment of herpes zoster (shingles) in patient 50 years of age or older. (an)

12/14/18 Routine annual policy review. No change to current policy. (an)

1/14/20 Routine policy review. Senior medical director approved 12/2019. No changes to policy statement. (an)

12/31/20 Routine policy review. Medical director approved 12/2020. No changes to policy statement. New code 90377 added to coding section. (eel)

4/20/21 Policy format update. No changes to policy statement.  (eel)  

8/10/21 Clarification made to rabies diagnosis usage in Billing and Coding section. (eel)

12/30/21 Routine policy review. Billing and Coding section updated with new codes expanding range from 90460-90756 to 90460-90759. Guidance in Billing and Coding section updated that Modifier 52 is not recognized to represent state-supplied vaccines. State-supplied vaccines are now to be submitted with Modifier SL. Medical Director approved. (eel)

6/1/22 Policy language updated throughout. Billing and Coding section updated to include G0008- G0010, Q2034-Q2039, and “Counseling related to administered vaccines is incidental to the administration codes (G0008-G0010, 90460-90461).” Added language for SHINGRIX in patients over 19 with special conditions as specified by the CDC. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

8/9/2022 Clarification that Modifier 25 must be used with all evaluation and management services when reporting a significant, separately identifiable service in addition to the immunization services. (ckb)

12/31/2022 Routine policy review. Clarification made to bill charge of $.01 for state supplied vaccines to mirror Bundling Guidelines. (ckb) 

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.