Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Physician Bulletin 90 April 2011 TO: Physicians Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: 2011 Pediatric Immunization Administration Codes Background Effective January 1, 2011, two new pediatric immunization administration CPT codes have replaced Service Codes 90465-90468. These codes are: 90460 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component 90461 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component In these descriptors, a component refers to each antigen in a vaccine that prevents disease caused by one organism. Combination vaccines are those vaccines that contain multiple vaccine components (i.e., MMR, DTaP, and DTaP/IPV). Reimbursement In accordance with guidelines from the Centers for Medicare & Medicaid Services (CMS), under the Vaccine for Children (VFC) program, MassHealth will reimburse for vaccine administration on a per vaccine basis, and not on a per antigen or per combination basis. Billing Guidelines Providers should use the new Service Code 90460 for vaccines and to use the same service code with modifier SL for state-supplied vaccines (90460-SL). When multiple vaccines are provided, providers should indicate the number of vaccines (units) administered. Please Note: A vaccine with multiple antigens or components should always be billed with one unit. Additionally, if Service Code 90461 is used for a vaccine with multiple antigens or components, it will be paid at $0 value. (continued on next page) MassHealth Physician Bulletin 90 April 2011 Page 2 Billing Guidelines (cont.) Providers are reminded that in accordance with 130 CMR 433.413(C), a provider may bill only for the injectable material and its administration when the immunization or injection is the primary purpose of an office or other outpatient visit. However, when the immunization or injection is not the primary purpose of the office or other outpatient visit, a provider may bill for both the visit and the injectable material, but not for its administration. MassHealth does not pay for the cost of the injectable material if (1) the Massachusetts Department of Public Health or a local board of health distributes the injectable material free of charge; or (2) its cost to the provider is $1.00 or less. See 130 CMR 433.413(C) and CMR 433.443(C)(2)(a). Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.