Fillable Printable Pcs Rates Vaccine Fa Qs

Pcs Rates Vaccine Fa Qs

New Requir ements for Submissi on of Cl aims f or Vacci ne Admi ni str ation

Frequent l y Asked Quest i ons

Revision Date: 3/29/2013—

This FAQ supersedes a ll prev io us FAQs a nd v a cc ine memos. I t pro v ides

clarification to Q & A #12 and additional FAQs are appended.

When does the provider need to start billing using the new methodology?

Per the federal requirements, the provider is required to use the new billing methodology for dates of

service on or after January 1, 2013.

Do all providers need to use the ne w cla ims billing method?

Yes, all providers need to use the new claims billing method.

When will eligible providers see an increase from the current VFC and non-VFC administration

rate?

Enhanced payments for qualifying claims with dates of service on or after January 1, 2013 will not

begin January 1 but will be made retroactively once CMS approval of the required Arizona state plan

amendment and methodology is received. Providers must meet the requirements as noted in the

12/11/12 memo

http://www.azahcccs.gov/commercial/downloads/rates/PCPInfoMemo.pdf

to be eligib le for the enhanced payment. CMS approval may be delayed as late as July 1, 2013.

Is the SL modifier used for both the vaccine and the vaccine administration codes?

Yes, the SL modifier is used for both the vaccine and the vaccine adminis tratio n codes under VFC

only. Vaccines for adults or non-VFC vaccines for children do not have the SL modifier added.

Will providers only receive payment for one administration code regardless of how many

vaccines were administered?

No, if the provider individually administers more than one vaccine, the provider can bill for the

administratio n of each vaccine, provided the additiona l

vaccines are administered through a separate

injection. The provider will not be paid fo r additional toxo id s in the same syringe. This mirrors the

current payment policy.

Providers cannot divide vaccines commonly administered in a single injection in order to report

multiple administrations. When medically necessary and appropriate to administer a second injection, a

second adminis trat io n fee may be paid.

Is 90461 an o pen c o de?

AHCCCS has opened this code as of January 1, 2013. However, under VFC no additional payment is

made for additional toxoids in the same syringe.

Can AHCCCS provide examples of code use?

The following examples illustrate several vaccine coding situations and are not meant to be all

inclusive. These examples do not reflect required NDC reporting. Refer to question #8 for more

information regarding the required NDC reporting.

NOTE: These examples illustrate reporting instructions under FFS claims billing. Contractors

may require different reporting methods due to varying claims system requirements. Please

consult the individua l Contractor for re porting ins tructions .

With the changes under the ACA, both the specific vaccine code and the vaccine administration code

must be reported by all providers reporting vaccine administration services.

• If the vaccine is provided through the VFC program, the SL modifie r must be a dded to bo th

the vaccine code and the vaccine administration code. Do not add the SL modifier to

vaccine and administr atio n codes used to report services provided to members who are 19 years

of age or older or for vaccines not covered under the VFC program administered to children.

• C PT c o d e s id e nti fy in g the va c c ine o r to xo id give n und e r t he VF C p r o gra m s ho uld be identified

with the appropriate CPT code to identify the vaccine, the SL modifie r, and the charge listed as

$0.00.

• Vaccines should be identified with the appropriate CPT code and the charge for that vaccine for

members 19 years of age or older or for vaccines not covered under the VFC program

administered to children.

Codes: 90460 & 90461

As no te d in Q5,

more than one vaccine administration payment can be made if multiple injections are

given to the member. Reporting multiple injections depends on which vaccine administration codes

are used to report the services. When more than one vaccine is administered with counseling to a

member 18 years of age or younger,

each single injection is reported with CPT administration code

90460 (first or only component of each vaccine or toxoid administered) a nd if covered under VFC, add

the SL modifier.

Providers will be paid a separate administratio n fee for each separate injection. If mo r e t han o ne

vaccine/toxoid is included in a single injection, the additional toxoids should be identified with the

appropriate CPT code and if covered under VFC, add the SL modifier. Adminis tra tio n of those other

components/toxoids may be identified with CPT code 90461 a nd if covered under VFC, add the SL

modifier.

AHCCCS will not make additional payment for administration of other additional toxoids included in

the injection identified with CPT code 90460. Providers are not compelled to report 90461 for the

administration of those additional toxoids.

Codes: 90471, 90472, 90473, 90474

W he n mo re tha n o ne inj ec tion is given to a me mb e r who is 19 years of age or older or to a

child without

counseling, the administration of the first injection is identified with CPT code 90471

and additional injections are identified with CPT code 90472. Each vaccine or toxoid component

should be identified with the appropriate CPT code on the claim form along with the charge for that

toxoid. Intranasal or oral administration should likewise be coded with CPT code 90473 and additional

administrations are identified with CPT code 90474.

Example 1: Child 18 years of age or under receiving one VFC injection

24. A B C D E F G

Dates of Service Place of Service EMG

Procedures, Services or

Supplies

Diagnosis

Poi nte r

$ Ch a rges Uni ts

1/1/13-1/1/13 11 90460 SL 1 $xx.xx 1

1/1/13-1/1/13

90700 SL

0.00

Example 2: Child 18 years of age o r under receiving three separate VFC injections

24. A

Dates of Service

Place of Service

EMG

Procedures, Services or

Supplies

Diagnosis

Poi nte r

$ Ch a rges

Uni ts

1/1/13-1/1/13

90460 SL

$xx.xx

1/1/13-1/1/13

90700 SL

0.00

1/1/13-1/1/13 11 90655 SL 1 0.00 1

1/1/13-1/1/13 11 90707 SL 1 0.00 1

Note: Examples 3 and 4 would also apply to non-VFC i njec ti ons fo r chi ldren.

Example 3: Member 19 years of age or older

receiving one injection

24. A B C D E F G

Dates of Service

Place of Service

EMG

Procedures, Services or

Supplies

Diagnosis

Poi nte r

$ Ch a rges

Uni ts

1/1/13-1/1/13

90471

$xx.xx

1/1/13-1/1/13 11 90656 1 $xx.xx 1

Example 4: Member 19 years of age or older

re ceiving three injections

24. A

Dates of Service

Place of Service

EMG

Procedures, Services or

Supplies

Diagnosis

Poi nte r

$ Ch a rges

Uni ts

1/1/13-1/1/13

90471

$xx.xx

1/1/13-1/1/13

90472

$xx.xx

1/1/13-1/1/13

90656

$xx.xx

1/1/13-1/1/13

90670

$xx.xx

1/1/13-1/1/13 11 90703 1 $xx.xx 1

Is the NDC required when billing VFC and non-VFC vaccine s e rvice s?

Yes the NDC is required. The current billing standards for reporting NDC information on the

Professiona l claim form for AHCCCS are consistent with the instruct io ns and standards for the

CMS1500 form as published by NUCC. To the extent an NDC is appropriate to report, the other

related data elements are also required by the form and the policy we have adopted.

Refer to the pharmacy web page at:

http://www.azahcccs.gov/commercial/Downloads/PharmacyUpdates/NDCBillingRequirementsFAQs_

Additional.pdf for additional information specific to NDC usage.

Are G0008, G0009 and G0010 administration codes el ig ible f o r the enha nc ed ra te?

No t hey a r e no t . Unde r 42 CFR 447. 400, only CPT codes 90460, 90461, 90471, 90472, 90473 and 90474

or their successor codes are eligible for the enhanced rate. Note that these codes are eligible for the

enhanced ra te only if the y are ope n code s within the State Medicaid program.

Q10

Recently several specialty societies issued guidance directing providers reporting vaccine and

vacci ne admin istr ati on ser vices on th e same d ate of ser vice as an Evalu ation and Man agement

(E&M) service, including Preventive Medicine exams, to add Modifier 25 to the E&M code. Do

the se ins tructions apply to claims submitte d to AHCCCS?

A10

CMS has added numerous code pairs to the Correct Coding Initiative (CCI) list of codes Procedure to

Procedure code edits. These new edits, effective 1/1/13, pair the vaccine adminis tra tio n codes (90460,

90461, and 90471-90474) with the E&M codes. These CCI edits do not allow both the vaccine

administr ation service and the E&M service to be paid for the same date of service unless the E&M

service is identified with modifier 25. A HCCCS mu s t adopt thes e CCI edits. Providers administering

vaccines and performing an E&M service on the same date of service must add modifier 25 to the

E&M code. Modifier 25 is not added to the vaccine administration codes.

Q11

Will the AHCCCS VFC administrat ion rate increas e to the ne w regional max imum fo r a ll

providers?

A11

No. AHCCCS has elected not to adopt the new regional maximum VF C rate . Providers who are

eligib le for enhanced payment rates will receive the enhanced rate of $21.33 for vaccine adminis tratio n

under VFC.

For all other vaccine administrations under VFC, the AHCCCS rate of $15.43 remains unchanged.

Q12

What are the potential AHCCCS v ac cine VFC and non-VFC adm inistr ation rates for eligible

and non-eligible phys icians for CY 2013 and 2014 once AHCCCS gains approval for the ir State

Pla n Amendment a nd metho do lo g y ?

Note: This s imple chart is inte nde d only to illus trate the reimbursement difference between

ACA-eligible and non-eligible providers, as well as bet ween VFC a nd no n-VFC administration

and doe s not provide for all continge ncie s.

A12

Example

Physician eligible

fo r enha nc ed f ees

Physician not eligible

for e nhance d fe es

Va cc ine pro v ided

through VFC

$21.33 / each separate injection

$15.43 / each separate injection

Vaccine not provi

ded thro ug h VFC

$26.81 / each separate injection

plus fee for vaccine/to xo id

$20.64 / each separate injection

p lus fe e for vaccine/toxoid

Q13

Can 90460 be us e d if the RN is giving the inje ction to a child?

A13

As lo ng a s the physician has counseled the member, 90460 may b e us e d w hen the nur se ha s give n the

injection.

Q14

For an adult, when there is a ser ies of three immuniz ations, the doctor consult s at the point of the f irst

immunization. W hen the member comes back f or the 2

and 3

inj ection and the RN gives the inj ection

does the nurse use 90471?

A14

The use of the code is dependent on whether or not the p hys ic ian ha s d o ne fo llo w up c o unse l in g to the

member.

Q15

If the physician administers multiple vaccine injections on the same day, will s/he be paid the

same administration rate for each injection?

A15

Yes the reimburse me nt rate will be the same for each administratio n of the injectio n.