Immunizations

HMSA Commercial plans cover immunizations in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP).

ACIP Recommendations

The Advisory Committee on Immunization Practices (ACIP) develops vaccine recommendations for children and adults. The recommendations include the age(s) when the vaccine should be given, the number of doses needed, the amount of time between doses, and precautions and contraindications.

All of the ACIP’s recommendations are posted on the Centers of Disease Control and Prevention (CDC) webpage at: https://www.cdc.gov/vaccines/hcp/acip-recs/.

COVID-19 Vaccine and Vaccine Administration codes.

For commercial members, as of 09/12/2023, COVID-19 vaccines will be commercially available and covered by HMSA. Coverage is limited to the administration codes, see COVID-19 Immunization Administration codes.

See Additional billing information.

The original monovalent vaccines’ emergency use authorization (EUA) has been rescinded and those vaccines are no longer recommended for use, effective November 1, 2023

• Please be sure to use the most up-to-date industry-standard procedure, revenue, and diagnosis codes from the current CPT ®′′, HCPCS Level II, and ICD-10-CM manuals, as recommended by the American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS), and the American Hospital Association.

♣Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently.

Claim Billing Examples^{• ♦}

♦ CPT, diagnosis codes and ACIP recommendations are subject to change and are used as reference examples only.

EXAMPLE 1

ACIP Hepatitis B recommendation state “all adults requesting protection from HBV infection, without requiring them to acknowledge a specific factor” should be vaccinated.

Adult member presents to a physician office requesting the Hepatitis B vaccination. The adult member does not disclose a specific risk factor and is not required.

Diagnosis:

• Z23 - Encounter for immunization

Code:

• 90746 - Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use
• 90471 – Immunization Administration

Modifier:

• No modifier necessary

EXAMPLE 2

ACIP Hepatitis A recommendation states “persons with end-stage renal disease, including predialysis, hemodialysis, peritoneal dialysis, and home dialysis patients” should be vaccinated.

Adult member presents to a physician office for Hepatitis A vaccine because the member is considered a high risk candidate due to End Stage Renal Disease.

Diagnosis:

• N18.6 - End stage renal disease
• Z99.2 - Dependence on renal dialysis
• Z23 - Encounter for immunization

Code:

• 90632 - Hepatitis A vaccine (HepA), adult dosage, for intramuscular use
  • Append modifier SK
• 90471 – Immunization Administration

Modifier:

• SK - Member of high risk population (use only with codes for immunization)

EXAMPLE 3

ACIP recommendation states, “pregnant people during 32 through 36 weeks gestation, using seasonal administration, to prevent RSV lower respiratory tract infection in infants” should be vaccinated. Member informs physician or other qualified healthcare professional provider that they are 33 weeks gestation.

Diagnosis:

• Z23 - Encounter for immunization
• Z3A.33 - 33 weeks gestation of pregnancy

Code:

• 90678 – Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use
• 90471 – Immunization Administration

Additional Billing Information^{• ♣ ♦}

• Bill the procedure code(s) representing the vaccine/toxoid and the appropriate administration code (s) on the same claim.
• HMSA prefers that a provider bills administration codes on a single line with a count (# of units).
• HMSA does not pay for vaccines provided by the State.Vaccines provided by the state should append modifier SL (State supplied vaccine) on the vaccine claim line with a nominal bill charge of $0.00. Note: IF system is limited and a charge is required, bill charge at $0.01.
• We encourage billing the COVID -19 vaccine & vaccine administration separately from other services rendered in the same visit.
• During the public health emergency (PHE) period, COVID-19 vaccines are funded by the federal government. Therefore, you are not required to bill for the COVID-19 vaccines (CPT 91300, 91301, or 91303).
• According to Noridian, UB claims billed for COVID-19 vaccine administration shall be billed with revenue code 0771 (Preventive Care Services – Vaccine Administration). Using other revenue codes may result to bundling into a case rate.
• Report CPT codes 90460 and 90461 only when the physician or other qualified healthcare professional provides face-to-face counseling to the patient/family during the vaccine administration.
• Code 90460 is reported once for the first component of each vaccine or toxoid administered by any route.
• Code 90461 is additionally reported for the counseling associated with each additional component of any combination vaccine or toxoid.
• A component refers to all antigens in a vaccine that prevents disease(s) caused by one organism. Multivalent antigens or multiple serotypes of antigens against a single organism are considered a single component of vaccines. Combination vaccines are those vaccines that contain multiple vaccine components. Conjugates or adjuvants in vaccines are not considered parts of the vaccine as defined above. See the reference table below.
• For more related information about vaccine and administration, refer to Immunization Administration Billed with Other Services for more related information.
• According to ACIP, effective September 22, 2023, * Maternal RSV vaccine is recommended for pregnant people during 32 through 36 weeks of gestation. Be sure to indicate the appropriate diagnosis code for the weeks of gestation. (e.g. Z3A.32, Z3A.33, Z3A.34, Z3A.35, or Z3A.36). Refer to https://www.cdc.gov/vaccines/hcp/acip-recs/ for the latest ACIP recommendation.

Components of Common Pediatric Vaccines

^• Please be sure to use the most up-to-date industry-standard procedure, revenue, and diagnosis codes from the current CPT ®′′, HCPCS Level II, and ICD-10-CM manuals, as recommended by the American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS), and the American Hospital Association.

^♣ Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently.

^♦CPT, diagnosis codes and ACIP recommendations are subject to change and are used as reference examples only.

Revision History