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—

ThisFAQ supersedesa llprev io us FAQs a nd v a cc inememos. I t pro v ides

clarificationto Q & A #12 and additionalFAQsareappended.

When doestheprovider need to start billingusingthe new methodology?

Per the federalrequirements, the provideris required to use the new billingmethodologyfordates of

serviceon or after January1, 2013.

Do all providersneed tousethene w cla ims billingmethod?

Yes, allproviders need to use the new claims billingmethod.

When will eligibleproviders seean increasefrom thecurrentVFC and non-VFC administration

rate?

Enhanced payments for qualifyingclaims withdates ofservice onor afterJanuary1, 2013 willnot

beginJanuary1 butwillbe made retroactivelyonce CMS approvalof therequiredArizona state plan

amendmentand methodologyis received. Providers mustmeet the requirements asnoted in the

12/11/12 memo

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

tobe eligib le for the enhanced payment. CMS approvalmaybe delayed as late as July1, 2013.

Is theSLmodifier used for both the vaccineand the vaccineadministration codes?

Yes, the SL modifieris used for both the vaccine and the vaccine adminis tratio ncodesunder VFC

only. Vaccines for adults or non-VFC vaccines for childrendonot have the SLmodifier added.

Will providersonly receivepayment for oneadministrationcoderegardlessof how many

vaccines were administered?

No, if the providerindividuallyadministersmore thanonevaccine, the provider canbill for the

administration of each vaccine, provided the additiona l

vaccines are administered through a separate

injection. The provider will notbe paidfo r additional toxo id sin the same syringe. Thismirrorsthe

current paymentpolicy.

Providers cannot divide vaccines commonlyadministered in a single injectionin ordertoreport

multiple administrations. Whenmedically necessaryand appropriate to administer a second injection, a

second adminis trat io nfee maybe paid.

Is90461 ano pen c o de?

AHCCCS hasopenedthiscode as ofJanuary 1, 2013. However, under VFCno additionalpaymentis

made for additionaltoxoids in the samesyringe.

CanAHCCCS provideexamples of code use?

Thefollowing examples illustrate several vaccine coding situations and are notmeant to be all

inclusive.Theseexamples do notreflect required NDC reporting. Referto question#8for more

information regarding therequiredNDCreporting.

NOTE: Theseexamplesillustrate reportinginstructions under FFSclaimsbilling.Contractors

mayrequire different reporting methodsduetovaryingclaimssystemrequirements.Please

consult the individua lContractor for re portingins tructions .

Withthe changes under the ACA, both the specific vaccine code and the vaccine administrationcode

must be reported byall providers reportingvaccine administrationservices.

•If thevaccine is providedthrough the VFCprogram,the SL modifie rmust bea dded to bo th

the vaccinecode and the vaccineadministrationcode. Do not add the SL modifierto

vaccine and administr atio ncodes used to report services provided to memberswho are 19 years

ofage or olderor for vaccines notcovered under the VFCprogramadministeredto 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 rt he VF Cp r o gra ms ho uld be identified

withthe appropriate CPTcode to identifythe vaccine, the SLmodifie r, and the charge listed as

$0.00.

•Vaccines should be identified with the appropriate CPTcode and the charge for that vaccinefor

members19 years of age or older or for vaccines notcovered under the VFCprogram

administeredto children.

Codes:90460 & 90461

As no te d in Q5,

more thanone vaccine administration payment canbe made ifmultiple injections are

given to the member. Reporting multiple injections depends onwhichvaccine administration codes

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

member 18 years of ageoryounger,

eachsingle injection is reported withCPTadministration code

90460 (first or only component ofeachvaccine ortoxoidadministered)a nd if covered under VFC, add

the SL modifier.

Providers willbe paid a separate administrationfee for eachseparate injection.If mo r e t han o ne

vaccine/toxoid isincluded in asingle injection, theadditional toxoidsshouldbeidentified with the

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

components/toxoidsmaybe identified withCPTcode 90461 a nd if covered under VFC, add the SL

modifier.

AHCCCS willnotmake additionalpayment for administrationof other additionaltoxoids includedin

the injection identified withCPTcode 90460. Providers are not compelled to report 90461 for the

administrationof those additionaltoxoids.

Codes: 90471, 90472, 90473, 90474

W he n mo re tha n o ne inj ec tion is given to a me mb e rwho is19years ofage or olderor to a

childwithout

counseling, the administration ofthe first injection is identified withCPTcode 90471

and additionalinjections are identified withCPT code 90472. Eachvaccine or toxoid component

should be identified with the appropriate CPTcode on the claimformalongwiththe charge for that

toxoid. Intranasalor oraladministrationshould likewise be coded withCPT code 90473 and additional

administrations are identified withCPT code 90474.

Example 1: Child18 years of ageorunderreceiving one VFC injection

24. A BCDE FG

Dates of ServicePlace of ServiceEMG

Procedures, Services or

Supplies

Diagnosis

Pointer

$ ChargesUnits

1/1/13-1/1/131190460 SL1 $xx.xx1

1/1/13-1/1/13

90700 SL

0.00

Example 2: Child 18years of ageo r underreceiving threeseparateVFC injections

24. A

Dates of Service

Place of Service

EMG

Procedures, Services or

Supplies

Diagnosis

Pointer

$ Charges

Units

1/1/13-1/1/13

90460 SL

$xx.xx

1/1/13-1/1/13

90700 SL

0.00

1/1/13-1/1/131190655 SL1 0.001

1/1/13-1/1/131190707 SL1 0.001

Note:Examples3 and4 wouldalso apply to non-VFCi njec ti onsfo r chi ldren.

Example 3: Member 19 years of ageorolder

receiving one injection

24. A BCDE FG

Dates of Service

Place of Service

EMG

Procedures, Services or

Supplies

Diagnosis

Pointer

$ Charges

Units

1/1/13-1/1/13

90471

$xx.xx

1/1/13-1/1/131190656 1 $xx.xx1

Example 4: Member 19 years of ageorolder

re ceiving three injections

24. A

Dates of Service

Place of Service

EMG

Procedures, Services or

Supplies

Diagnosis

Pointer

$ Charges

Units

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

1/1/13-1/1/1311907031 $xx.xx1

Is theNDC required when billingVFCand non-VFC vaccine s e rvice s?

Yesthe NDC is required.Thecurrentbilling standardsforreporting NDCinformation on the

Professiona lclaimformfor AHCCCS are consistentwiththe instruct io ns and standards for the

CMS1500 formas published byNUCC. To the extent an NDCis appropriate to report, the other

related data elements are also required by the formand the policywe have adopted.

Referto the pharmacy webpage at:

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

Additional.pdf foradditional information specific toNDCusage.

Are G0008, G0009 and G0010 administration codesel ig ible f o r theenha nc ed ra te?

Not hey a r e no t . Unde r 42 CFR 447. 400,only CPT codes90460, 90461, 90471, 90472, 90473 and 90474

or their successorcodes are eligible for the enhanced rate. Note thatthese codes are eligible for the

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

Q10

Recentlyseveral specialtysocieties issued guidancedirectingprovidersreportingvaccineand

vacci neadmin istr ati on ser vices on th esame d ateof ser vice as an Evalu ation and Man agement

(E&M)service, includingPreventive Medicine exams, toaddModifier25 to the E&M code. Do

the se ins tructions apply toclaims submitte d toAHCCCS?

A10

CMS has added numerous code pairs to the CorrectCodingInitiative (CCI) listof codes Procedure to

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

90461, and 90471-90474) withthe E&M codes. These CCI edits donotallow boththe vaccine

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

serviceisidentified withmodifier 25.A HCCCS mu s tadopt thes e CCI edits.Providers administering

vaccines andperforminganE&M service onthe same date of service must add modifier 25to the

E&M code. Modifier 25 isnotadded to the vaccine administrationcodes.

Q11

Will the AHCCCS VFC administrat ion rateincreas etothe ne w regional max imumfo r a ll

providers?

A11

No. AHCCCShas elected not to adopt the new regionalmaximumVF C rate . Providers who are

eligib le for enhanced paymentrates willreceive the enhanced rate of $21.33 for vaccine adminis tratio n

under VFC.

For allother vaccine administrations underVFC, the AHCCCS rate of$15.43 remains unchanged.

Q12

Whatare thepotentialAHCCCS v ac cine VFC and non-VFC adm inistr ation rates foreligible

and non-eligible phys icians for CY2013 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 toillus trate the reimbursementdifference between

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

and doe snotprovide for all continge ncie s.

A12

Example

Physician eligible

fo r enha nc ed f ees

Physician noteligible

for e nhance d fe es

Va cc ine pro v ided

through VFC

$21.33 / eachseparate injection

$15.43 / eachseparate injection

Vaccinenotprovi

ded thro ug h VFC

$26.81 / eachseparate injection

plus fee for vaccine/to xo id

$20.64 / eachseparate injection

p lus fe e for vaccine/toxoid

Q13

Can 90460 be us e difthe RN is giving the inje ctiontoa child?

A13

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

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 notthep hys ic ian ha s d o ne fo llo wup c o unse l in g to the

member.

Q15

Ifthe physician administersmultiplevaccine injectionson thesameday,wills/he be paid the

same administrationrateforeach injection?

A15

Yes the reimburse me ntrate willbe the same for each administratio nof the injectio n.