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.

Coverage of immunizations may fall under Medicare Part B or Part D.

Medicare generally excludes coverage of immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. Examples of these Part D immunizations include anti-rabies treatment, tetanus antitoxin, or booster vaccines. Medicare also cover the following vaccines as a part of preventive care under Part B: Flu vaccine, pneumonia vaccine, and hepatitis B vaccine.

Policy

Immunization services are allowed in accordance with Medicare and the member’s certificate benefits.

Reimbursement Guidelines

Blue Cross Medicare Advantage follows Medicare guidelines for reimbursement of immunizations.

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 codes (90460-90474).

Please refer to the Blue Book for more information.

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 except preventive services CPT 99381-99397, 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.

The following guidelines can be used for appropriate coding of rabies prophylaxis:

Pre-Exposure Prophylaxis:

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 product codes to represent vaccines that are statesupplied.

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

Related Policy

n/a

References

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Vaccines-Part-D-Factsheet-ICN908764.pdf

https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/medicare-vaccine-coverage.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/PreventiveServicesPoster.pdf

Blue Cross NC Medicare Provider Manual (Blue Book)
https://www.bluecrossnc.com/sites/default/files/document/attachment/providers/public/pdfs/Provider_Manual.pdf

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)

History

6/1/22 - New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/22 - Routine Policy Review. Minor revisions only. (cjw)

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) 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.