Pediatric Coding Alert

Keep in mind, however, that state rules may vary.

Your practice is most certainly familiar with the Vaccine for Children (VFC) program, but you may not be aware of the myriad state-specific steps involved in collecting payment for administering these vaccines. The following three FAQ answers can help you find your way to smooth sailing when you see your next VFC patient.

FAQ 1: How Do We Report the Administration But Not the Product?

Under the VFC program, immunization supplies for Medicaid patients are provided free of charge, but you can bill for immunization administration. However, many Medicaid programs still want you to report the specific vaccine so they can track what has been used. To report the product without charging for it, the rules will vary from state to state, and each state may have multiple steps to collect.

For example: “Ohio Medicaid Fee-for-Service wants the doctor to bill under the vaccine product and not an immunization administration code,” says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. “They then pay $10.00, which is considered the immunization administration payment even though we only billed the vaccine product code.”

“However,” Tuck says, “If the patient’s insurance is under Ohio’s Medicaid managed care instead, the payment rules vary based on the individual company you have contracts with even within the same state. They’ll often want us to report 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) for each vaccine given or 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) if it’s a product given. Even if it has multiple components they won’t want us to bill +90461 (…each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) for individual components. That’s an example of how complicated it can be just in my state of Ohio.”

Other states will allow you to report the entire series of vaccine administration codes for the VFC service and may pay significantly more than the Ohio allowed amount. The key is to get a copy of your state’s regulations in writing before you try and guess how to code these services.

FAQ 2: Are All Vaccines Covered Under the VFC Program?

Unfortunately, even once you’ve nailed down your state’s process for billing vaccines under the VFC rules, you still have a few more hurdles to jump before you’ll start collecting. The first is to confirm which vaccinations your state actually covers.

For instance: The state of California’s policy states, “Measles-Rubella (MR), single-antigen tetanus and mumps vaccines are not supplied by the VFC program and continue to be reimbursed by Medi-Cal. Reimbursement for the purchase of these vaccines must be billed with the appropriate codes.”

In addition, the California VFC program requires you to document why a patient requires a preservative-free formulation of the flu shot if you report 90655 (Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use).

Other states may have similar policies, or may pay MR but not influenza, so get a list of payable vaccines from your VFC provider.

FAQ #3: Are Modifiers Required?

In some instances, your state may require that you append a modifier such as SL (State supplied vaccine) to your administration code.

For example: In Arizona, you must report your VFC claims using both the specific vaccine code and the vaccine administration code. “If the vaccine is provided through the VFC program, the SL modifier must be added to both the vaccine code and the vaccine administration code,” the policy states. “Do not add the SL modifier to vaccine and administration 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.”

Typically, in states like Arizona where you must report both the administration and supply codes, you’ll report a $0.00 charge for the supply since the state provides it for free, and the state will pay you its allotted amount for the administration.

Bottom line: Because Medicaid providers have state-specific rules about how to report these vaccines, always get your policy in writing. If the policy doesn’t address issues such as required modifiers or payment amounts, ask your provider services representative for written documentation of how the payer requires you to deal with those topics.