Medicaid Vaccine and Immunization CPT code list

Pediatric Flu Vaccine: Special Situations 

In the event a Medicaid provider does not have VFC pediatric influenza vaccine on hand tovaccinate a high priority VFC eligible Medicaid enrolled child, the provider should use pediatric influenza vaccine from private stock, if available. If a provider does use vaccine from private stock for a high priority VFC eligible Medicaid enrolled child, the provider would then replace dose(s) used from private stock with replacement dose(s) from VFC stock when VFC vaccine becomes available. The provider should not turn away, refer or reschedule a high priority VFC eligible Medicaid enrolled child for a later date if vaccine is available. Louisiana Medicaid will update Medicaid enrolled providers through remittance advices and the Louisiana Medicaid Provider Update regarding availability of vaccine through the VFC program and any billing issues. Please contact the Louisiana VFC Program office at (504)838-5300 for vaccine availability information.



* indicates the vaccine is available from the Vaccines For Children (VFC) program

^ indicates the vaccine is payable for QMB Only and QMB Plus recipients Vaccine

Code Description

90476^ Adenovirus vaccine, type 4, live, for oral use

90477^ Adenovirus vaccine, type 7, live, for oral use

90581^ Anthrax vaccine, for subcutaneous use

90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use

90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use

90632 Hepatitis A vaccine, adult dosage, for intramuscular use

90633* Hepatitis A vaccine pediatric/adolescent dosage, 2-dose schedule, for intramuscular use

90634* Hepatitis A vaccine, pediatric/adolescent dosage, 3-dose schedule, for intramuscular use

90636 Hepatitis A and Hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use

90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use

90646 Hemophilus Influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use

90647* Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use

90648* Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use

90649* Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use

90655* Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for
intramuscular use

90656* Influenza virus vaccine, split virus, preservative free, when administered to 3 years and older, for intramuscular use

90657* Influenza Virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use

90658* Influenza Virus vaccine, split virus, when administered to 3 years of age and older, for intramuscular use

90660* Influenza Virus vaccine, live, for intranasal use

90665^ Lyme Disease vaccine, adult dosage, for intramuscular use

90669* Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use

90675^ Rabies vaccine, for intramuscular use

90676^ Rabies vaccine, for intradermal use

90680* Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use

90690^ Typhoid vaccine, live, oral

2007 Louisiana Medicaid Professional Services Provider Training 100


Vaccine Codes

Code Description

90691^ Typhoid vaccine, Vi capsular polysaccharide (ViCPS), for intramuscular use

90692^ Typhoid vaccine, heat-and phenol-inactivated (H-P) for subcutaneous or intradermal use

90693 Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (US Military)

90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated, (DTaP-Hib-IPV), for intramuscular use

90700 * Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to younger than 7 years, for intramuscular use

90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use

90702* Diphtheria and tetanus toxoids (DT) absorbed when administered to younger than 7 years, for intramuscular use

90703 Tetanus toxoid adsorbed, for intramuscular use

90704 Mumps virus vaccine, live, for subcutaneous use

90705 Measles virus vaccine, live, for subcutaneous use

90706 Rubella virus vaccine, live, for subcutaneous use

90707* Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous

90708 Measles and rubella virus vaccine, live, for subcutaneous use

90710* Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use

90712 Poliovirus vaccine, (any type(s)) (OPV), live, for oral use

90713* Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use

90714* Tetanus and diphtheria toxoids, (Td) absorbed, preservative free, when administered to 7 years or older, for intramuscular use

90715* Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to 7 years or older, for
intramuscular use

90716* Varicella virus vaccine, live, for subcutaneous use

90717 Yellow fever vaccine, live, for subcutaneous use

90718* Tetanus and diphtheria toxoids (Td) adsorbed when administered to7 years or older, for intramuscular use

90719 Diphtheria toxoid, for intramuscular use

90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use

90721* Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DTaP-Hib), for intramuscular use

90723* Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DTaP-HepB-IPV), for intramuscular use

90725 Cholera vaccine for injectable use

90727 Plague vaccine, for intramuscular use

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to 2 years or older, for subcutaneous or intramuscular use

90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use

90734* Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for

2007 Louisiana Medicaid Professional Services Provider Training 101

Vaccine Codes

* indicates the vaccine is available from the Vaccines For Children (VFC) program

^ indicates the vaccine is payable for QMB Only and QMB Plus recipients


90735 Japanese Encephalitis Virus vaccine, for subcutaneous use

90736 Zoster (shingles) vaccine, live, for subcutaneous injection

90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use

90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use

90744* Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use

90746* Hepatitis B vaccine, adult dosage, for intramuscular use

90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use

90748* Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use



• Procedure code 90703 (Tetanus toxoid - for trauma) will be payable at the rate of $2.42, and it is not available through the VFC program.

• If the administration units for 90466, 90468, 90472 or 90474 are greater than the number of vaccines reported for the administration codes, the units will be cutback to reflect the number of vaccine codes being reported.

• If the administration units for 90466, 90468, 90472 or 90474 are less than the number of vaccines reported the claim will be processed based on the units listed for administration.

Billing CPT 90281 Immune Globulin

Coding for Immune Globulins, Vaccines and Toxoids

CPT-Codes (Current Procedural Terminology) are assigned by the AMA and used to bill for Immune Globulins, Vaccines and Toxoids.

•	Immune Globulins: Products listed include broad-spectrum and anti-infective immune globulins, antitoxins, and various isoantibodies;
•	Vaccines/Toxoids: Multiple codes for a particular vaccine/toxoid are provided when the schedule (number of doses or timing) differs for two or more products of the same vaccine type (e.g., hepatitis A, HiB) or the vaccine product is available in more than one chemical formulation, dosage, or route of administration. Separate codes are available for combination vaccines (e.g., DTP-Hib, DtaP-Hib, and HepB-Hib). It is inappropriate to code each component of a combination vaccine separately. If a specific vaccine, toxoid or immune globulin code is not available, the unlisted CPT® code 90749 (vaccines/toxoids) or 90399 (immune globulins) should be reported, until a new code becomes available.

Reimb Code	Description	Effective Date	Code Price	Code Price-5%
90281	Immune Globulin (Ig), human, for intramuscular use (Code price is per 2 mL)	10/01/09	$38.83	$36.89

CPT CODE 62310, 62311 - Epidural injection

procedure code and description

62310 - Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic - Average fee amount $230 - 260

62311 - Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) Average fee amount $230 - 260

62318 - Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

62319 - Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) - average fee payment - $150 - $180

Billing Guidelines

Only one (1) unit of 62310, 62311, 62318 or 62319 should be billed and allowed per spinal region [cervical/thoracic, lumbar/sacral (caudal)], no matter how many injections are made in that region.

The CPT codes 62310, 62311, 62318, and 62319 each have a bilateral surgery indicator of "0." Modifier -50 and/or the anatomic modifiers, -LT/-RT should not be used.

The CPT codes 64479-64484 (transforaminal epidurals) have a bilateral surgery indicator of "1." Thus, they are considered "unilateral" procedures and the 150% payment adjustment for bilateral procedures applies. When injecting a nerve root bilaterally, file with modifier –50. When injecting a nerve root unilaterally, file the appropriate anatomic modifier –LT or –RT.

Only one (1) unit of service should be submitted for a transforaminal epidural injection for a unilateral or bilateral injection at the same level.

Whether a transforaminal epidural injection is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.

CPT codes 62310, 62311 should be used when the analgesia is delivered by a single injection.

These codes should only be used when the catheter or injection is not used for administration of anesthesia during the operative procedure. Modifier -59 should be used when billing these services to indicate that the catheter or injection was a separate procedure from the surgical anesthesia care.

The epidural catheter insertion (CPT codes 62318 or 62319) includes the setup and start of the infusion. Therefore, the daily management of epidural or subarachnoid drug administration (CPT code 01996) should not be billed for the same day as the catheter insertion.

The daily management of epidural or subarachnoid drug administration (CPT code 01996), is a daily service and should only be coded with a number of services (NOS) of one (1) for each day billed. Post-operative pain management services should be reported in the inpatient hospital setting (21) only.

When performed primarily for postoperative pain management the time utilized for a single injection (CPT codes 62310 and 62311) or the insertion of the epidural catheter (CPT codes 62318 and 62319) should not be included in the time reported for the anesthesia care for the surgical procedure. The catheter insertion is considered a surgical procedure and should be coded with the number of services of one (1).

** Preoperative evaluations for anesthesia are included in the fee for the administration of anesthesia and may not be billed as an E&M service.

** Regional IV anesthesia (e.g., 01995) is not based on time units; the base unit is covered. Therefore, only one unit of service may be billed. CPT 01995 is used only in situations involving the application of a tourniquet to a limb and injection of an agent for regional anesthesia.

** CPT surgical procedure codes (e.g., 62311 and 62319) are used for regional anesthesia. No base units or time units of anesthesia may be billed. Instead, one unit of service (an injection) is billed.

** Epidural for pain management other than the three stages of delivery (labor, delivery, and postpartum) must be billed with CPT 62311 and 62319. Time units may not be billed.

** CPT 01996 (Daily Management of Epidural or Subarachnoid Drug Administration) is not payable on the same day as the insertion of an epidural catheter or a general anesthesia service. The service unit for this procedure is one base unit.

** Epidural anesthesia for surgical procedures must be billed with the appropriate **0** anesthesia code with time units.

** Medications for pain relief given during the time of the epidural anesthesia are inclusive and must not be billed as a separate procedure.

** Local anesthesia and IV (conscious) sedation are bundled into the procedure being provided and must not be billed as separate services.

** Anesthesia services rendered during a hysterectomy or sterilization require completion, submission, and acceptance of the appropriate acknowledge/consent forms.

** Occasionally a procedure which is usually requires no anesthesia or local anesthesia, because of unusual circumstances, must be rendered under general anesthesia. A written description of the reason for using modifier 23 is required, and the claim will be sent for review.


WV Medicaid‘s payment policy for labor epidural is as follows:

** Labor epidural provided by the surgeon must be billed with the appropriate delivery anesthesia code and modifier 97. Labor epidural provided by the anesthesiologist and/or CRNA must be billed with the appropriate **0** anesthesia code

** CPT surgical codes 62311 and 62319 are not to be used to bill pain management for the three stages of delivery.

** Medications for pain relief given during the time of the epidural anesthesia are not covered as a separate procedure.

** Only one provider or team will be paid for epidural services.

** Emergency anesthesia is not allowed with the provision of epidural anesthesia or vaginal deliveries.

** The labor epidural procedures covered by WV Medicaid are inclusive of labor, delivery, and postpartum care. Additional procedure codes used for pain management are not covered.

** Modifiers defining the CRNA or anesthesiologist participation are used in processing to allocate payments. (e.g., AD,QK,QX,QY, and QZ) The supervising/medical directing anesthesiologist/ CRNA must bill the same procedure code.

** Physical status modifiers are not used for processing by WV Medicaid. The billing of additional base units for physical status is prohibited.

Coverage Indications, Limitations, and/or Medical Necessity

    Epidural injections are used for the treatment of multiple different conditions in chronic and acute pain. Epidural injections may be used for therapeutic and/or diagnostic purposes. There are multiple approaches to epidural injections including caudal, translaminar, and transforaminal. These different approaches are used for different but specific indications. (In general it is felt that the closer the injection can be placed to the pathology the more likely to achieve a beneficial response). Correct placement is best confirmed by using fluoroscopic guidance and injection of contrast.

    Epidural injections and/or infusions will be considered medically reasonable and necessary for the following conditions:

    1. Management of pain caused by intervertebral disc disease with or without myelopathy.

    2. Management of pain caused by spinal stenosis.

    3. Management of intractable radicular pain due to postlaminectomy syndrome/failed back syndrome.

    4. Management of intractable pain due to complex regional pain syndrome.

    5. Management of intractable pain due to post herpetic neuralgia and acute herpes zoster.

    6. Management of intractable pain due to traumatic neuropathy of the spinal nerve roots.

    7. Management of intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or metabolic).

    8. Management of severe, intractable pain in patients with advanced stages of cancer with estimated life expectancy of 4 months or less.

    9. Management of pain caused by radiculitis (inflammation of the nerve roots).

    Low back pain may also be produced by “Myofascial Pain Syndrome” in which case there is not nerve root pathology and epidural injections are not reasonable and necessary. If there is a doubt in the differential diagnosis, the diagnosis of radiculopathy can be confirmed by an EMG/nerve conduction/small fiber testing or appropriate radiological study. Degenerative Disk Disease without root compression has been shown to be a significant cause of low back and/or radicular pain; some patients will respond to Epidural Steroid Injection in this situation.

    Epidural injections, with the exception of interlaminar injections, should be performed under fluoroscopic or CT-guided imaging. Therefore, injections for chronic pain performed without imaging guidance are considered not medically reasonable or necessary.


Indications

These procedures are used to inject a substance into the subarachnoid, subdural or epidural space for the relief of pain or spasticity. The following list of examples is not all inclusive of the indications for injections of the spinal canal.

Intervertebral disc disease (with neuritis, radiculitis, sciatica) with or without myelopathy;

Complex regional pain syndrome;

Post herpetic neuralgia;

Traumatic neuropathy of the spinal nerve roots;

Postlaminectomy syndrome (failed back syndrome);

Chronic severe pain due to carcinoma;

Acute and chronic postoperative pain;

Chronic upper and lower extremity radicular symptoms (i.e. spinal stenosis).
Prior to any interventional pain procedure and regardless of the longevity of pain (i.e. acute, subacute, chronic, etc.), a patient must have failed to respond to conservative management. Examples of conservative management include physical therapy modalities, chiropractic manipulation, and medication management. The fact that a patient has chronic pain does not preclude the option of a retrial of conservative management at some point during their care. Although conservative management should be attempted, this requirement may be waived for the infrequent patient who is unable to tolerate it.

Limitations

An injection session is defined as all injection services of the spinal canal administered during a 24 hour period for a specific date of service per region (cervical, thoracic or lumbosacral). Therefore,

In the first year, up to six (6) injection sessions per region may be performed: up to two (2) diagnostic and up to four (4) therapeutic.
In the following years, up to four (4) therapeutic injection sessions per region may be performed.

There is limited peer-reviewed medical literature substantiating the use of alcohol, phenol, or iced saline solutions for either subarachnoid or epidural pain relief (CPT codes 62280, 62281, 62282). Use of these codes requires specific narrative documentation supporting the use of either alcohol, phenol, or iced saline solutions.

The use of fluoroscopic or computed tomographic (CT) guidance is required when performing injections of the spinal canal. Transforaminal epidural injections with ultrasound guidance (CPT codes 0228T - 0231T) will be denied as investigational.

Performance of more than one type of injection for pain treatment, such as epidural, sacroiliac joint injections or lumbar sympathetic injections, on the same day as a diagnostic spinal injection is not considered reasonable and necessary.

Clinicians performing these services must have appropriate training in interventional pain management and radiographic guidance. Documentation of this training must be maintained at the site of practice.

CPT/HCPCS Codes
  
    For Single Injection

    62310 Inject spine cerv/thoracic
    62311 Inject spine lumbar/sacral

    For Transforaminal Epidural Injections
 
    64479 Inj foramen epidural c/t
    64480 Inj foramen epidural add-on
    64483 Inj foramen epidural l/s
    64484 Inj foramen epidural add-on

Coding Guidelines

1. The HCPCS/CPT code(s) may be subject to Correct Coding initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the current version CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

2. All procedures related to pain management procedures performed by the physician/provider performed on the same day must be billed on the same claim.

3. An imaging guidance code is billed only once per session for CPT code 77003, fluoroscopy or CPT code 77012 for CT guidance. Physicians may only bill for the professional component when imaging is performed in a hospital or non-office facility. No claim should be submitted for the hard or digital film(s) maintained to document needle placement.

4. The CPT code 72275 (Epidurography, radiological supervision and interpretation) differs from CPT code 77003 in that it represents a formal recorded and reported contrast study that includes fluoroscopy. Epidurography should only be reported when it is reasonable and medicallynecessary to perform a diagnostic study. Epidurography should not be billed when the contrast injection is part of the fluoroscopic guidance and contrast injection to confirm correct needle placement that is integral to the epidural, transforaminal and intrathecal injections addressed in the policy.

5. All the CPT codes applicable to this policy include allowance for the insertion of the needle into the epidural space, as well as the injection of the drug.

6. Only one (1) unit of 62310, 62311, 62318 or 62319 should be billed and allowed per spinal region [cervical/thoracic, lumbar/sacral (caudal)], no matter how many injections are made in that region.


7. The CPT codes 62310, 62311, 62318, and 62319 each have a bilateral surgery indicator of "0." Modifier -50 and/or the anatomic modifiers, -LT/-RT should not be used.

8. The CPT codes 64479-64484 (transforaminal epidurals) have a bilateral surgery indicator of "1." Thus, they are considered "unilateral" procedures and the 150% payment adjustment for bilateral procedures applies. When injecting a nerve root bilaterally, file with modifier –50. When injecting a nerve root unilaterally, file the appropriate anatomic modifier –LT or –RT.

9. Only one (1) unit of service should be submitted for a transforaminal epidural injection for a unilateral or bilateral injection at the same level.

10.Whether a transforaminal epidural injection is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.

11. CPT codes 62310, 62311 should be used when the analgesia is delivered by a single injection.

12. These codes should only be used when the catheter or injection is not used for administration of anesthesia during the operative procedure. Modifier -59 should be used when billing these services to indicate that the catheter or injection was a separate procedure from the surgical anesthesia care.

13. The epidural catheter insertion (CPT codes 62318 or 62319) includes the setup and start of theinfusion. Therefore, the daily management of epidural or subarachnoid drug administration (CPT code 01996) should not be billed for the same day as the catheter insertion.

14. The daily management of epidural or subarachnoid drug administration (CPT code 01996), is a daily service and should only be coded with a number of services (NOS) of one (1) for each day billed. Post-operative pain management services should be reported in the inpatient hospital setting (21) only.

15. When performed primarily for postoperative pain management the time utilized for a single injection (CPT codes 62310 and 62311) or the insertion of the epidural catheter (CPT codes 62318 and 62319) should not be included in the time reported for the anesthesia care for the surgical procedure. The catheter insertion is considered a surgical procedure and should be coded with the number of services of one (1).

Only one (1) unit of 62310, 62311, 62318 or 62319 should be billed and allowed per spinal region [cervical/thoracic, lumbar/sacral (caudal)], no matter how many injections are made in that region

The CPT codes 62310, 62311, 62318, and 62319 each have a bilateral surgery indicator of "0." Modifier -50 and/or the anatomic modifiers, -LT/-RT should not be used.

CPT codes 62310, 62311 should be used when the analgesia is delivered by a single injection.

When performed primarily for postoperative pain management the time utilized for a single injection (CPT codes 62310 and 62311) or the insertion of the epidural catheter (CPT codes 62318 and 62319) should not be included in the time reported for the anesthesia care for the surgical procedure. The catheter insertion is considered a surgical procedure and should be coded with the number of services of one

Old description and New description

62310 Inject spine c/t             Inject spine cerv/thoracic 

62311 Inject spine l/s (cd)          Inject spine lumbar/sacral

Bundling Issues with ESI Procedures

The 64479 code is Unbundled in the CCI Edits from code 62310 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Code 64483 is Unbundled from code 62311 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Therefore, for Medicare and other payors who observe the CCI edits, these codes are not billable together when they are performed at the SAME spinal area. If the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L4-5, the procedures are Unbundled and not both billable – only code 62311 would be billable in that case. However, if the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L3-4, then it is allowable to put a -59 Modifier on the 64483 code and bill it as the 2nd code following the 62311 ESI code on the claim form.


ICD-10 Codes that Support Medical Necessity
   
    For procedures codes: 62310, 62311, 64479, 64480, 64483 and 64484

    A52.15 Late syphilitic neuropathy
    B02.0 Zoster encephalitis
    B02.23 Postherpetic polyneuropathy
    B02.24 Postherpetic myelitis
    B02.29 Other postherpetic nervous system involvement
    C30.0 Malignant neoplasm of nasal cavity
    C30.1 Malignant neoplasm of middle ear
    C31.0 Malignant neoplasm of maxillary sinus
    C31.1 Malignant neoplasm of ethmoidal sinus
    C31.2 Malignant neoplasm of frontal sinus
    C31.3 Malignant neoplasm of sphenoid sinus
    C31.8 Malignant neoplasm of overlapping sites of accessory sinuses
    C31.9 Malignant neoplasm of accessory sinus, unspecified
    C32.0 Malignant neoplasm of glottis
    C32.1 Malignant neoplasm of supraglottis
    C32.2 Malignant neoplasm of subglottis
    C32.3 Malignant neoplasm of laryngeal cartilage
    C32.8 Malignant neoplasm of overlapping sites of larynx
    C32.9 Malignant neoplasm of larynx, unspecified
    C33 Malignant neoplasm of trachea
    C34.00 Malignant neoplasm of unspecified main bronchus
    C34.01 Malignant neoplasm of right main bronchus
    C34.02 Malignant neoplasm of left main bronchus
    C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
    C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
    C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
    C34.2 Malignant neoplasm of middle lobe, bronchus or lung
    C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
    C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
    C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
    C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
    C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
    C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
    C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
    C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
    C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
    C37 Malignant neoplasm of thymus
    C38.0 Malignant neoplasm of heart
    C38.1 Malignant neoplasm of anterior mediastinum
    C38.2 Malignant neoplasm of posterior mediastinum
    C38.3 Malignant neoplasm of mediastinum, part unspecified
    C38.4 Malignant neoplasm of pleura
    C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura
    C39.0 Malignant neoplasm of upper respiratory tract, part unspecified
    C39.9 Malignant neoplasm of lower respiratory tract, part unspecified
    C40.00 Malignant neoplasm of scapula and long bones of unspecified upper limb
    C40.01 Malignant neoplasm of scapula and long bones of right upper limb
    C40.02 Malignant neoplasm of scapula and long bones of left upper limb
    C40.10 Malignant neoplasm of short bones of unspecified upper limb
    C40.11 Malignant neoplasm of short bones of right upper limb
    C40.12 Malignant neoplasm of short bones of left upper limb
    C40.20 Malignant neoplasm of long bones of unspecified lower limb
    C40.21 Malignant neoplasm of long bones of right lower limb
    C40.22 Malignant neoplasm of long bones of left lower limb
    C40.30 Malignant neoplasm of short bones of unspecified lower limb
    C40.31 Malignant neoplasm of short bones of right lower limb
    C40.32 Malignant neoplasm of short bones of left lower limb
    C40.80 Malignant neoplasm of overlapping sites of bone and articular cartilage of unspecified limb
    C40.81 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb
    C40.82 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb
    C40.90 Malignant neoplasm of unspecified bones and articular cartilage of unspecified limb
    C40.91 Malignant neoplasm of unspecified bones and articular cartilage of right limb
    C40.92 Malignant neoplasm of unspecified bones and articular cartilage of left limb
    C41.0 Malignant neoplasm of bones of skull and face
    C41.1 Malignant neoplasm of mandible
    C41.2 Malignant neoplasm of vertebral column
    C41.3 Malignant neoplasm of ribs, sternum and clavicle
    C41.4 Malignant neoplasm of pelvic bones, sacrum and coccyx
    C41.9 Malignant neoplasm of bone and articular cartilage, unspecified
    C43.0 Malignant melanoma of lip
    C43.10 Malignant melanoma of unspecified eyelid, including canthus
    C43.11 Malignant melanoma of right eyelid, including canthus
    C43.12 Malignant melanoma of left eyelid, including canthus
    C43.20 Malignant melanoma of unspecified ear and external auricular canal
    C43.21 Malignant melanoma of right ear and external auricular canal
    C43.22 Malignant melanoma of left ear and external auricular canal
    C43.30 Malignant melanoma of unspecified part of face
    C43.31 Malignant melanoma of nose
    C43.39 Malignant melanoma of other parts of face
    C43.4 Malignant melanoma of scalp and neck
    C43.51 Malignant melanoma of anal skin
    C43.52 Malignant melanoma of skin of breast
    C43.59 Malignant melanoma of other part of trunk
    C43.60 Malignant melanoma of unspecified upper limb, including shoulder
    C43.61 Malignant melanoma of right upper limb, including shoulder
    C43.62 Malignant melanoma of left upper limb, including shoulder
    C43.70 Malignant melanoma of unspecified lower limb, including hip
    C43.71 Malignant melanoma of right lower limb, including hip
    C43.72 Malignant melanoma of left lower limb, including hip
    C43.8 Malignant melanoma of overlapping sites of skin
    C43.9 Malignant melanoma of skin, unspecified
    C44.00 Unspecified malignant neoplasm of skin of lip
    C44.01 Basal cell carcinoma of skin of lip
    C44.02 Squamous cell carcinoma of skin of lip
    C44.09 Other specified malignant neoplasm of skin of lip
    C44.101 Unspecified malignant neoplasm of skin of unspecified eyelid, including canthus
    C44.102 Unspecified malignant neoplasm of skin of right eyelid, including canthus
    C44.109 Unspecified malignant neoplasm of skin of left eyelid, including canthus


Documentation Requirements

Medical necessity for providing the service must be clearly documented in the patient’s medical record and submitted upon request for review.
Assessment of the outcome of this procedure depends on the patient’s responses, therefore documentation should include:

    Whether the block was a diagnostic or therapeutic injection
    Pre and post procedure evaluation of patient
    Patient education
    Subjective and objective response from the patient regarding pain provocative maneuvers documented by pre and post procedure measurement


According to the American Society of Interventional Pain Physicians (ASIPP) guidelines, a positive response to a series of three (3) epidural injections, is noted when > 50 % relief is obtained for 6 to 8 weeks.

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

It is expected that providing an epidural block in conjunction with multiple facet joint blocks, bilateral sacroiliac joint injections, trigger point injections, and/or lumbar sympathetic blocks in any combination to a patient on the same day is not considered medically necessary, unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management. It is expected that interlaminar, transforaminal or caudal epidural injections are not performed on the same date of service at the same level.

Procedures performed during the diagnostic phase should be limited to two (2) injections.

Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure.

In the treatment or therapeutic phase, a series of three (3) injections may be given at a minimum interval of two (2) weeks to the suspect level. If a positive response (per ASIPP guidelines) is not obtained, then a repeat series of injections at that level is considered not medically necessary.

It is not expected that a patient would undergo an epidural injection at more than two (2) levels (unilateral or bilateral) on any given date of service. (A level is defined as the articulation between two vertebrae i.e., C4-5; or L2-3).

A series of three (3) epidural injections may be repeated at six (6) month intervals (assuming there was a positive response as defined by the ASIPP guidelines) to the first series of three (3) injections. Caution should be used to monitor the side effects of frequent steroid use.

Under unusual circumstances with a recurrent injury, carcinoma, or reflex sympathetic dystrophy, blocks may be repeated more frequently in the treatment phase after stabilization. Documentation must be present in the medical record to support the more frequent use of such therapy in this setting.

CPT code 90460, 90471 - VFC Immunization administration

CPT CODE and description

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 administere -average fee amount - $20 - $30

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 or toxoid component administered (List separately in addition to code for primary procedure)


90471 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

90472 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)


Policy Guidelines

If a significantly separately identifiable evaluation and management service is provided at the time of vaccine administration, the evaluation and management service should be reported in addition to the vaccine and toxoid procedure.

Separate reimbursement will be allowed for preventive medicine services 99381-99397.

Separate reimbursement will be allowed for the administration of the vaccines codes (90460-90474).

Vaccines for Children (VFC)

VFC is covered under Section 1928 of the Social Security Act. Implemented on October 1, 1994, it was an “unprecedented approach to improving vaccine availability nationwide by providing vaccines free of charge to VFC-eligible children through public and private providers.”

The goal of VFC is to ensure that no VFC-eligible child contracts a vaccine preventable disease because of his/her parent’s inability to pay for the vaccine or its administration.


Persons eligible for VFC vaccines are between the ages of birth through 18 who meet the following criteria:

* *  Eligible for Medicaid

* *  No insurance

* *  Have health insurance, but it does not offer immunization coverage and they receive their immunizations through a Federally Qualified Health Center

* *  Native American or Alaska native

Providers can obtain an enrollment packet by contacting the Office of Public Health’s (OPH) Immunization Section at (504) 838-5300.

Guidelines for Reporting Immunization Administration

Codes 90460 and 90461 or 90471–90474 are reported in addition to vaccine/toxoid code(s) 90476– 90749.

• Codes 90460 and 90461 do not differentiate by routes of administration or "first" versus "each additional" administration.

• The age designation for codes 90460 and 90461 (ie, through age 18) is consistent with the age requirements under the federal Vaccines for Children (VFC) program.

• When the physician or qualified health care professional (eg, nonphysicians if allowed under state scope of practice) provides face-to-face counseling for the patient and family during the administration of a vaccine to a patient aged 18 years or younger, code 90460 or a combination of codes 90460 and 90461 are reported. The medical record documentation must support that the physician or other qualified health care professional provided the vaccine counseling.

• Code 90460 is reported for the first component of each vaccine administered whether it is a single or combination vaccine.

• Code 90461 is reported in conjunction with 90460 for each additional component in a given vaccine. The word "component" refers to each antigen in a vaccine that prevents disease(s) caused by one organism. Combination vaccines are those vaccines that contain multiple vaccine components (antigens).

• The immunization administration codes include the provider (ie, physician or other qualified health care professional) work of discussing risks and benefits of the vaccines, providing parents with a copy of the Centers for Disease Control and Prevention (CDC) Vaccine Information Statement (VIS) for each component, the cost of the nursing time to record each component administered in the medical record and statewide vaccine registry, giving the vaccine, observing and addressing reactions or side effects, and the cost of supplies (eg, syringe, needle, bandages).

• When the physician or qualified health care professional does not perform the vaccine counseling to the patient or family, or when vaccines are administered to patients older than 18 years, codes 90471– 90474 are reported instead of codes 90460–90461. Codes 90471–90474 are reported as appropriate based on their current guidelines (ie, either 90471 or 90473 is reported for the first vaccine administered to a patient on a calendar date, and codes 90472 and 90474 are reported for each additional vaccine given on the same date based on its route of administration). Coding Vaccine/Toxoid Products

CPT codes 90476–90749 are used to report vaccine/toxoid products. They are always reported separately from immunization administration codes (90460–90461, 90471–90474). Each specific vaccine product administered must be reported to meet the requirements of immunization registries, vaccine distribution programs, and reporting systems (eg, Vaccine Adverse Event Reporting System).

Each vaccine/toxoid product code is specific to the product manufacturer and brand, chemical formulation, specific schedule (number of doses or timing), dosage, appropriate age guidelines, and route of administration. Close attention must be paid to the specific product code and descriptor to ensure that the correct code is reported. For example, there are 8 codes available for reporting the influenza virus vaccine (90655–90663). Each product is different, and the differences can be subtle.

It would be incorrect, for example, to report 90655 (influenza virus vaccine, split virus, preservative free, for children 6–35 months of age, for intramuscular use) when administering influenza virus vaccine, split virus, 6 to 35 months' dosage, for intramuscular use (code 90657).

When a combination vaccine is administered, its specific code should be reported. Never report each component of a combination vaccine separately unless the components are administered and the combination vaccine is not administered. Typically the only times components are reported rather than combination vaccines is when the physician elects to administer the component vaccines because of nonavailability of the combination vaccine, or there is clinical reason for administering each component separately.

Modifier 51 (multiple procedures) should not be reported with vaccines/toxoids or immunization administration codes.

To avoid vaccine coding errors, a practice's encounter form would ideally only include the specific codes for the vaccines that are administered by the practice. It is neither necessary nor desirable to include every product code on the practice superbill.

V67.59 as primary, educate it by providing a copy of the ICD-9-CM guidelines. If the payer continues to refuse to follow the guidelines, get its policy in writing. Code 90471 is reported because the physician or other qualified health care professional did not perform the vaccine counseling. If state scope of practice includes nurses within the definition of "other qualified health care professionals," code 90460 would be reported instead of 90471.

7. A 4-year-old is seen for her preventive medicine visit. She is given her second dose of the measles, mumps, rubella, and varicella (MMRV) vaccine and her fourth dose of the DTaP-IPV vaccine. Although the physician personally performed the counseling for both vaccines, the medical record only supports face-to-face counseling for the MMRV vaccine.

Immunization Guidelines

Applicable Codes: 90460-90749, G0008, G0009, G0010, Q2034-Q2039

Codes 90460 and 90461 must be reported in addition to the vaccine and toxoid codes 90476-90749.

Report codes 90460-90461 only when the physician or qualified health care professional provides faceto-face counseling of the patient and family during the administration of a vaccine. For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family for administration of vaccines to patients over 18 years of age, report codes 90471-90474.

Codes 90476-90748 identify the vaccine product only. To report the administration of a vaccine/toxoid, the vaccine product code must be used in addition to the administration code 90460-90474. Modifier 51 should not be reported for the vaccines/toxoids when performed with these administration procedures.

Each immunization given must be filed on a single line of the CMS 1500 claim form, with its specific CPT code.

The -25 modifier must be used with all evaluation and management services except preventive services CPT 99381-99397, when reporting a significant, separately identifiable service in addition to the immunization services.

It is inappropriate to use the unlisted vaccine code CPT 90749 to report immunization administration services.

The invoice from the laboratory or pharmacy the vaccine has been purchased from may be requested for claim review.

ZOSTAVAX® (Zoster Vaccine Live), has FDA approval for use in prevention of herpes zoster (shingles) in individuals 50 years of age and older.


Vaccines For Childern (VFC) Billing Instructions through 18 years of age: Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code. Lastly, in field 407-D7 (Product/Service ID), enter the Procedure Code. Providers may submit up to 4 claim lines with one transaction. For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age). For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.

* Vaccines for individuals under the age of 19 are provided free of charge by the VFC program. Medicaid WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the  VFC program. For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration.

* Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor often issues an executive order allowing pharmacies to immunize patients less than 19 years of age. Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85. By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.




Immunization Administration Codes 90460 and 90461

Effective May 23, 2011, a daily maximum limit of nine units for CPT code 90460 and five units for 90461 will be assigned. A duplicate procedure edit will apply to charges submitted for CPT code 90460 exceeding nine units and 90461 exceeding five units per date of service. Effective February 20, 2012, the daily maximum limit for CPT Code 90461 will increase to seven. The daily maximum limit for CPT Code 90460 will remain at nine units.  Respiratory Treatment Demonstration or evaluation of patient use of an aerosol generator, nebulizer, metered dose inhaler, or IPPB devise (CPT code 94664) is considered mutually exclusive to an office visit.

Immunization CPT along with E & M codes


Previously announced as a revision to the Rebundling Policy and effective in the first quarter of 2014, UnitedHealthcare will deny Preventive Medicine Evaluation and Management (E/M) services (CPT codes 99381-99397) when reported on the same date of service as an immunization administration service (CPT codes 90460-90461 and 90471-90474) through the CCI Editing Policy. This change aligns with the CMS National Correct Coding Initiative (NCCI) and the American Medical Association Current Procedural Terminology (CPT®)

If modifier 25 is reported with the Preventive Medicine E/M service and the documentation supports that a significant and separately identifiable E/M service was provided on the same date as the administration service, both would be reimbursed. It would not be appropriate to additionally report the Preventive Medicine E/M code for the counseling provided when a vaccine is administered.



Immunization Administration Codes 90460 and 90461

Effective May 23, 2011, a daily maximum limit of nine units for CPT code 90460 and five units for 90461 will be assigned. A duplicate procedure edit will apply to charges submitted for CPT code 90460 exceeding nine units and 90461 exceeding five units per date of service. Effective February 20, 2012, the daily maximum limit for CPT Code 90461 will increase to seven. The daily maximum limit for CPT Code 90460 will remain at nine units.  Respiratory Treatment Demonstration or evaluation of patient use of an aerosol generator, nebulizer, metered dose inhaler, or IPPB devise (CPT code 94664) is considered mutually exclusive to an office visit.

Medicaid billing Guide for Immunization Administration

Billing Instructions for 19 years of age and older: 

Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure code.  Lastly, in field 407-D7 (Product/Service ID), enter the Procedure code.  Providers may submit up to 4 claim lines with one transaction.  For example, providers may submit one claim line with the Procedure code 90656 (Influenza Virus Vaccine), and another claim line for Procedure code 90471 (Immunization Administration through 19 years of age and older).  For administration (ages 19 and older) of multiple vaccines on the same date, code 90471 should be used for the  first vaccine and 90472 for ANY other vaccines administered on that day. One line will be billed for 90472 indicating the additional number of vaccines administered (insert 1 or 2).

Vaccines For Childern (VFC) Billing Instructions through 18 years of age:  

Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code.  Lastly, in field 407-D7 (Product/Service ID), enter the Procedure Code.  Providers may submit up to 4 claim lines with one transaction.  For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age).  For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.

** Vaccines for individuals under the age of 19 are provided free of charge by the VFC program. Medicaid WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the VFC program.  For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration.

 ** Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor often issues an executive order allowing pharmacies to immunize patients less than 19 years of age.   Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85.  By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.

If a clinical staff member performs vaccine administration with or without counseling under the supervision of the provider and, reports the service under the supervising provider, CPT codes 90471 , 90474 must be reported

Vaccine Administration Codes and Reimbursement Rates

The following codes should be used for all vaccine administration, including VFC vaccine administration for members 18 years old and younger. Report these codes in addition to the vaccine and toxoid code(s).

CPT Code          Description                Rate

Use the following codes for vaccine administration to patients of any age when the administration is not accompanied by any face-to-face counseling, or for administration to patients over 18 with or without counseling:

90471 (Including percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccines/toxoid) (do not report in conjunction with 90473) $21.68


+ 90472 Each additional vaccine/toxoid (List separately in addition to 90471, 90473) $12.59


90473 By intranasal or oral route; one vaccine (single or combination vaccine/toxoid) (do not report in conjunction with 90471)  $21.68


+ 90474 Each additional vaccine/toxoid administered by intranasal or oral route (List separately in addition to 90471, 90473) $12.59

Using Vaccine Administration Codes 90471-90474

The immunization administration codes 90471-90474 need to be billed as one (1) line item, and the vaccine product should be billed as a separate line item. In order for an immunization claim to be reimbursed both an administration code and the vaccine product must be billed. If an immunization is the only service rendered, providers may not submit charges for an E&M service.

Adult immunizations are reimbursed at the lower of: billed charges, or the Medicaid fee schedule amount  for each immunization.

Note: Providers are not to bill CPT codes 90471-90474 for children ages 0-18 for whom counseling was given (see section “Using Pediatric Immunization Codes 90460 and 90461” in this manual). CPT Codes 90471-90474 must only be billed for members (ages 19 and older) or members ages 18 and under for whom no counseling was given.

1. Patient/Parent are not counseled on 2 multi-component vaccines. Both are injectables. Patient is 5 years old.

90471 and 90472

Teaching point: Even though the patient meets the age requirement, counseling is not done.


2. Patient/Parent are counseled by the nurse on 2 multiple component vaccines. Both are injectables. Patient is 5 years old.


90471 and 90472

Teaching point: Even though the patient meets the age requirement, vaccine is done by clinical staff (nurse) and therefore
does not meet the OQHCP requirement.


Vaccine Administration Billing Instructions:

• Code the primary vaccine administration code (CPT 90460, 90471, or 90473), the diagnosis code and the EP modifier.

o CPT 90460 should be used to indicate face-to-face counseling was associated with the vaccine administration. CPT 90460 may be billed with more than one unit.

o CPT 90471 and CPT 90473 should be used when there is no face-to-face counseling associated with the vaccine administration. CPT 90471 and CPT 90473 must be billed with a unit value of “1.”

• Code the vaccine product code with the applicable diagnosis code and the EP modifier.

• Code the applicable add-on vaccine administration code (CPT 90472 or 90474) with the appropriate number of units, the diagnosis code and the EP modifier.


o CPT 90472 or CPT 90474 must be coded if more than one non-counseled vaccine was administered.

o CPT 90460 may be used in conjunction with the add-on vaccine administration codes CPT 90472 and CPT 90474 to indicate that first vaccine administered was counseled and the additional vaccines administered were non-counseled.

• Each vaccine administration code should be listed only one time per claim. If multiple vaccine product codes correspond to the same vaccine administration code, the vaccine administration code is listed once with the appropriate number of units indicated.

• The vaccine administration code should be billed with the appropriate charges as outlined in the Department of Community Health Check Services Manual.


Note: This vaccine administration claim example is incorrect for the following reasons:

1. Vaccine administration code CPT 90460 does not precede all vaccines on the claim.

2. Vaccine administration code CPT 90460 is billed with $0.00 charges. The vaccine administration code should be billed with the applicable allowed amount.

3. Vaccine product codes CPT 90744 and 90700 are billed with charges. Charges for vaccine administration should be appended to the vaccine administration code.

Coding for Immunization Administration: Component-based and Injection-based Coding

An immunization administration code must be reported in addition to the vaccine or toxoid product code in order to be paid for the administration service. There are 2 code sets that may be used when billing for administration, depending on the age of the patient and whether or not counseling was performed.

If the patient is 18 years of age or under, and counseling was performed by the physician or other qualified health care professional, component-based administration codes are used. These codes are based on the number of components in the vaccine, and a unit of administration is billed for each component. A component is defined as each disease for which the vaccine is intended to provide protection.

These codes apply to all routes of administration, including injectable, intranasal, and oral.

• 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.

• 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 or toxoid component administered.

• Example: All flu vaccines are intended to offer protection against 1 disease, influenza, and are considered single-component vaccines billed with 1 unit of 90460.

• Example: Pentacel vaccine is intended to protect against 5 diseases, diphtheria, tetanus, acellular pertussis, polio, and Haemophilus b influenza and is considered a 5-component vaccine. Bill 1 unit of 90460 and 4 units of 90461. If the patient is 19 years of age or over, or if they are 18 years of age or under and counseling was not performed, use the code set that is based on number of injections administered at that visit (90471–90472). Note that because all Sanofi Pasteur vaccines are injectable, only 90471 and 90472 are applicable. (Products administered via oral or intranasal use 90473-90474.)

• 90471 – Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid).

• 90472 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid)

• Example: Fluzone and Adacel vaccines are administered to a patient that is 25 years of age. Bill 1 unit of 90471 for the Fluzone vaccine and

1 unit of 90472 for the Adacel vaccine


Immunizations and Vaccines

Immunizations Covered Under the Texas Vaccines for Children program

CPT Code Description

90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)

90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure.)

90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)

90632 Hepatitis A vaccine, adult dosage, for intramuscular use

90633 Hepatitis A vaccine, pediatric/adolescent dosage – 2-dose schedule, for intramuscular use

90634 Hepatitis A vaccine, pediatric/adolescent dosage – 3-dose schedule, for intramuscular use

90636 Hepatitis A and Hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use

90645 Haemophilus influenza b vaccine (Hib), HbOC conjugate (4-dose schedule), for intramuscular use

90646 Haemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use

90647 Haemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3-dose schedule), for intramuscular use

90648 Haemophilus influenza b vaccine (Hib), PRP-T conjugate (4-dose schedule), for intramuscular use

90649 Human Papilloma Virus (HPV) vaccine (Gardasil)*

*The HPV vaccine will be considered for reimbursement to Providers for patients ages 9 to 18 when the vaccine is not available through the Texas Vaccines for Children (TVFC) program. Providers should submit claims with the U1 modifier.

When billed without a modifier, the procedure code is informational only, allowing Providers to be paid the administration fee. In addition, the HPV vaccine will be payable to Providers who administer the HPV vaccine for patients ages 19 to 20.

Providers enrolled in TVFC must use TVFC as the source of the HPV vaccine for eligible patients when TVFC has HPV available for shipment.

CPT Description  Code

90655 Influenza virus vaccine, split virus, preservative free, for children 6–35 months of age, for intramuscular use

90657 Influenza virus vaccine, split virus, for children 6–35 months of age, for intramuscular use

90658 Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use

90669 Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use

90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for use in individuals younger than 7 years, for intramuscular use

90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use

90702 Diphtheria and tetanus toxoids (DT) adsorbed, for use in individuals younger than 7 years, for intramuscular use

90703 Tetanus toxoid absorbed, for intramuscular use

90705 Measles virus vaccine, live, for subcutaneous use

90706 Rubella virus vaccine, live, for subcutaneous use

90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

90710 Measles, mumps, rubella and varicella vaccine (MMRV)

90712 Poliovirus vaccine, any types (OPV), live, for oral use

90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular  use

90714 Tetanus and diphtheria toxoids (Td) absorbed, preservative free, for use in individuals 7 years or older, for intramuscular use

90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for use in individuals 7 years or older, for intramuscular use

90716 Varicella virus vaccine, live, for subcutaneous use

90718 Tetanus and diphtheria toxoids (Td) adsorbed, for use in individuals 7 years or older, for intramuscular use

90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Haemophilus influenza b vaccine (DTP-Hib), for intramuscular use

90721 Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Haemophilus influenza b vaccine (DtaP-Hib), for intramuscular use

90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immuno-suppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use

90733 Meningococcal polysaccharide vaccine (any groups), for subcutaneous use

90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use

90743 Hepatitis B vaccine, adolescent (2-dose schedule), for intramuscular use

90744 Hepatitis B vaccine, pediatric/adolescent dosage (3-dose schedule), for intramuscular use

90746 Hepatitis B vaccine, adult dosage, for intramuscular use

90748 Hepatitis B and Haemophilus influenza b vaccine (HepB-Hib), for intramuscular use

Modifier Description
SK Members of high-risk population

Immunization Administration Procedures Covered Under the TVFC Program


CPT Code Description Immunization Administration

90465 First injection, single or combination vaccine/toxoid, per day.

Immunization administration in patients younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family.

90466 Each additional injection, single or combination vaccine/toxoid, per day. (List separately in addition to code for primary procedure.)

90467 First administration, single or combination vaccine/toxoid, per day. Immunization administration in patients younger than 8 years of age (includes intranasal or oral routes of administration) when the physician counsels the patient/family.

90468 Each additional administration, single or combination vaccine/toxoid, per day. (List separately in addition to code for primary procedure.)

90471 One vaccine, single or combination vaccine/toxoid. Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections).

90472 Each additional vaccine, single or combination vaccine/toxoid. (List separately in addition to code for primary procedure.)

90473 One vaccine, single or combination vaccine/toxoid. Immunization administration(includes intranasal or oral route).

90474 Each additional vaccine, single or combination vaccine/toxoid (list separately in addition to code for primary procedure.).


INJECTIONS A CHILD RECEIVES IN ONE DAY.

A rule published in the Louisiana Register states: The Bureau of Health Services Financing does not reimburse providers for a single-antigen vaccine and its administration if a combinedantigen vaccine is medically appropriate and the combined vaccine is approved by the Secretary of the United States Department of Health and Human Services. (Louisiana Register, Volume 20, Number 3)


Reimbursement

In order for providers to receive reimbursement for the administration of appropriate immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) in the current Immunization Schedule, providers must indicate the CPT code for the specific vaccine in addition to the appropriate administration CPT code(s). The listing of the vaccine on
the claim form is required for federal reporting purposes.

For recipients age birth through 18 years, vaccine CPT codes will be paid at zero ($0) because the provider obtains the vaccine from the Vaccines for Children Program at no cost. For recipients age 19 through 20 years, providers should submit claims with their usual and customary charge for the vaccine and the claims will be reimbursed at the fee on file or the
billed charge, whichever is lower.

Billing For a Single Administration

Providers should bill the appropriate CPT immunization administration code(s) 90465, 90467, 90471, or 90473 (Immunization administration…first injection/first administration/one vaccine) when administering one immunization. The next line on the claim form must contain the specific CPT code for the vaccine, with $0.00 in the “billed charges” column (see pg. 102 for an
example).

• Do not report CPT codes 90465 and 90467 on the same date of service

• Do not report CPT codes 90471 and 90473 on the same date of service


Billing for Multiple Administrations

When administering more than one immunization, providers should bill as described above for a single administration. The appropriate procedure code(s) 90466, 90468, 90472, and 90474 (Immunization administration…each additional injection/administration/vaccine) should then be listed with the appropriate number of units for the additional vaccines placed in the “units” column. The specific vaccines should then be listed on subsequent lines. The number of specific vaccines listed after CPT administration codes should match the number of units listed in the units column. Examples of this scenario are on pages 103 through 107.

• Use CPT codes 90466 and/or 90468 with 90465 OR 90467 to report more than one vaccine administered. Do NOT use 90466 and/or 90468 with 90471 or 90473.

• Use CPT codes 90472 and/or 90474 with 90471 OR 90473 to report more than one vaccine administered. Do NOT use 90472 and/or 90474 with 90465 or 90467.

Hard Copy Claim Filing for Greater Than Four Administrations

When billing hard copy claims for more than four immunizations and the six-line claim form limit  is exceeded, providers should bill on two CMS-1500 claim forms. The first claim should follow the instructions above for billing the single administration. A second CMS-1500 claim form should be used to bill the remaining immunizations as described above for billing multiple administrations. An example is shown on pages 104 and 105.

Coverage of Vaccines for Recipients Age 19 through 20 Years Louisiana Medicaid is in the process of updating programming for immunizations including the ACIP recommended vaccines for recipients aged 19 through 20 years of age (e.g. Human Papilloma Virus, Influenza). Providers will be notified when these changes have been implemented.

For recipients age19 through 20 years, providers should submit claims reporting the appropriate immunization administration CPT code along with the specific CPT code and their usual and customary charge for the vaccine administered. The claims will be reimbursed at the fee on file or the billed charge, whichever is lower for the vaccine and administration.

Pediatric Flu Vaccine: Special Situations

In the event a Medicaid provider does not have VFC pediatric influenza vaccine on hand to vaccinate a high priority VFC eligible Medicaid enrolled child, the provider should use pediatric influenza vaccine from private stock, if available. If a provider does use vaccine from private stock for a high priority VFC eligible Medicaid enrolled child, the provider would then replace dose(s) used from private stock with replacement dose(s) from VFC stock when VFC vaccine becomes available. The provider should not turn away, refer or reschedule a high priority VFC eligible Medicaid enrolled child for a later date if vaccine is available. Louisiana Medicaid will update Medicaid enrolled providers through remittance advices and the Louisiana Medicaid Provider Update regarding availability of vaccine through the VFC program and any billing issues. Please contact the Louisiana VFC Program office at (504)838-5300 for vaccine availability information.

IMMUNIZATIONS

A review of immunization status shall be performed at each well child visit, with immunizations  administered according to recommendations and standards of practice recognized by the AAP and th  Advisory Committee on Immunization Practices (ACIP). Providers are reminded that all immunizations must be reported to the Michigan Care Improvement Registry (MCIR). (Refer to the Directory Appendix for contact information.)

Immunizations are covered when administered according to ACIP recommendations. MDHHS encourages providers to immunize all Medicaid beneficiaries.

* For Medicaid eligible children 18 years of age and younger, the Vaccines for Children (VFC) Program provides covered immunizations at no cost to the provider.

* Medicaid covers immunizations for beneficiaries 19 years of age and older. * Any LHD in the state can be contacted for specifics about the VFC program.


For immunizations available free of charge under the VFC program, the amount a provider may charge for vaccine administration may be limited. Providers cannot charge more for services provided to Medicaid beneficiaries than for services provided to their general patient population. For example, if the charge for administering a vaccine to a private-pay patient is $5.00, then the charge for immunization administration to the Medicaid beneficiary cannot exceed $5.00.

Medicaid Health Plan (MHP) providers enrolled in the VFC program are encouraged to immunize and are discouraged from referring beneficiaries to a LHD for these services. (Refer to the Practitioner Chapter for additional information.)

Medicaid - IMMUNIZATIONS IN APGS:

When seasonal flu, H1N1, and pneumococcal vaccines are provided in Article 28 hospital OPD or free-standing D&TC clinics (including SBHCs, county health dept. clinics, FQHCs, and part-time clinics), vaccine administration charges and vaccine charges, if applicable, must be billed as an ordered ambulatory service. All other vaccines (except those provided by the Vaccines for Children Program) are reimbursed through APGs when administered in the ambulatory care setting.

Effective January 1, 2010, vaccine administration codes (90465-90474, G0008-G0010, G9141) will group to APG 490 (incidental to medical visit/significant procedure) and will not pay separately at the line level. Providers who are administering State-supplied vaccines to Medicaid enrollees under the age of 19 years through the Vaccines for Children program, must bill for the vaccine administration as an ordered ambulatory service (not APGs) using the procedure code for the vaccine, appended with the modifier SL (to indicate a State-supplied vaccine). Providers will be reimbursed a $17.85 administration fee. 4.15 MRIS IN APGS:

MRIs were previously carved-out of the clinic threshold rate. When an MRI was provided to a clinic patient, either on the same day that the patient was seen in the clinic or on a subsequent day, clinics were instructed to bill Medicaid for the MRI as an ordered ambulatory service. Under APGs, MRIs provided to clinic patients should not be billed as an ordered ambulatory service. Clinics must bill for the MRI under the appropriate APG rate code (1400 or1432 for hospital OPDs and 1407 or 1422 for D&TCs). Payment will be made through the APG payment methodology. MRIs provided during an Emergency Department encounter should be included on the Medicaid claim under Rate Code 1402 and will be paid through the APG assigned for the visit. Effective January 1, 2010, medical visits will no longer package with MRIs and both the medical visit and MRI will pay at the line level.

CPT CODE 27096, G0259, g0260 - SACROILIAC (SI) JOINT INJECTIONS

cpt code and description

27096 - Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed - average fee amount - $120 - $160

G0259 - Injection procedure for sacroiliac joint; arthrograpy

G0260 - Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

Medicare Guideline update

Payment to Ambulatory Surgical Centers (ASCs) for G0260 and to Physicians for 27096 when 27096 is Performed in an ASC Note: This article was updated on April 5, 2013, to reflect current Web addresses. All other information remains unchanged.

Provider Types Affected

Physicians and ambulatory surgical centers.

Provider Action Needed 

STOP – Impact to You

Some Medicare carriers have been reimbursing incorrectly for sacroiliac joint injection of anesthetic agents or steroids (HCPCS code G0260) when the procedure is performed in an Ambulatory Surgical Center (ASC). Also, due to several inadvertent coding conflicts, physicians at ASCs who perform an injection procedure for a sacroiliac joint, arthrography, and/or anesthetic/steroid (Procedure  code 27096) may be reimbursed incorrectly as well.

HCPCS code G0260 (sacroiliac joint injection of anesthetic agents or steroids) was added to the list of approved ASC procedures for services performed on or after July 1, 2003 (CMS-1885-FC, 3/28/03).

Therefore, when a therapeutic sacroiliac joint injection is administered to a Medicare beneficiary at an  Ambulatory Surgical Center, it should be reported by the ASC as HCPCS code G0260.HCPCS code G0260, however, is not payable under the Medicare Physician Fee Schedule (MPFS). Physicians use CPCS code 27096 to bill for sacroiliac joint injection of anesthetic agents or steroids. SinceHCPCS code 27096 was not on the list of Medicare approved ASC procedures, physicians may have been overpaid when performing this procedure in an ASC.

To rectify this problem, carriers have been instructed to add CPT code 27096 to their file of ASC approved procedures. Physicians who perform a sacroiliac joint injection of anesthetic agents or steroids (CPT code 27096) will now be reimbursed at the correct rate under the Medicare physician fee schedule.

Please note that, for those Medicare carriers who did not make this change in a timely manner, there is a time lag between the effective date of July 1, 2003 and their new implementation date of February 2, 2004. Given this difference, claims that are submitted on or after the effective date for date of service, but prior to the implementation date, will be processed under the old rules. If this has affected your payments, you may wish to submit adjustment claims after February 2 in order to correct the payment. 

Coverage Indications, Limitations, and/or Medical Necessity

    The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain. Low back pain of SI joint origin is a difficult clinical diagnosis and often one of exclusion. Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source. If the cause of pain in the lower back has been determined to be the SI joint, one of the options of treatment is injecting steroids and/or anesthetic agent(s) into the joint. Therapeutic injections of the SI joint would not likely be performed unless other noninvasive treatments have failed.

    Image guidance is crucial to identify the optimal site for access to the joint. Fluoroscopy is often the imaging method of choice. Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected. Contrast fills the joint to delineate integrity (or lack thereof) of articular cartilage, as well as morphologic features of the joint space and capsule. Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid. Since fluoroscopy is the key to precision diagnostic injections and accurate therapeutic injections, procedure code 27096 should be billed when imaging confirmation of intra-articular needle positioning has been performed, since this code includes both the injection and the image guidance procedure.

    The injection procedure of the SI joint will be considered medically reasonable and necessary when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without therapeutic injection. In addition, the injection procedure of the SI joint will be considered medically necessary when an injection is given for therapeutic indications, such as injection of an anesthetic and/or steroid, to block the joint for immediate and potentially lasting pain relief. When therapeutic injections of the SI joint are performed, it would be expected that the record reflects noninvasive treatments (i.e., rest, physical therapy, NSAID’s, etc.) have failed.

SACROILIAC (SI) JOINT INJECTIONS 

The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain.


The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain. Low back pain of SI joint origin is a difficult clinical diagnosis and often one of exclusion. Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source. If the cause of pain in the lower back has been determined to be the SI joint, one of the options of treatment is injecting steroids and/or anesthetic agent(s) into the joint. Therapeutic injections of the SI joint would not likely be performed unless other noninvasive treatments have failed.

Image guidance is crucial to identify the optimal site for access to the joint. Fluoroscopy is often the imaging method of choice. Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected. Contrast fills the joint to delineate integrity (or lack thereof) of articular cartilage, as well as morphologic features of the joint space and capsule. Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid. Since fluoroscopy is the key to precision diagnostic injections and accurate therapeutic injections, procedure code 27096 should be billed when imaging confirmation of intra-articular needle positioning has been performed, since this code includes both the injection and the image guidance procedure.

The injection procedure of the SI joint will be considered medically reasonable and necessary when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without therapeutic injection. In addition, the injection procedure of the SI joint will be considered medically necessary when an injection is given for therapeutic indications, such as injection of an anesthetic and/or steroid, to block the joint for immediate and potentially lasting pain relief. When therapeutic injections of the SI joint are performed, it would be expected that the record reflects noninvasive treatments (i.e., rest, physical therapy, NSAID’s, etc.) have failed.

SACROILIAC (SI) JOINT INJECTIONS 

The sacroiliac (SI) joint is a diarthrodial, synovial joint which is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain.

STOP – Impact to You

Some Medicare carriers have been reimbursing incorrectly for sacroiliac joint injection of anesthetic agents or steroids (HCPCS code G0260) when the procedure is performed in an Ambulatory Surgical Center (ASC). Also, due to several inadvertent coding conflicts, physicians at ASCs who perform an injection procedure for a sacroiliac joint, arthrography, and/or anesthetic/steroid (CPT code 27096) may be reimbursed incorrectly as well.



CAUTION – What You Need to Know

Some Medicare carriers may not have been paying the facility fee to ASCs when they billed Medicare for HCPCS code G0260—injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrogrophy. In addition, due to several inadvertent coding conflicts, physicians may not have been paid correctly for HCPCS code 27096—injection procedure for sacroiliac joint, arthrography, and/or anesthetic steroid—when administered in an ASC. Both of these issues apply to services rendered on or after July 1, 2003



Be aware that carriers reimburse a facility fee to the ASC for HCPCS code G0260 for services performed on or after July 1, 2003, and that physicians who perform HCPCS 27096 is an ASC should be reimbursed the non-facility payment amount.



Background

HCPCS code G0260 (sacroiliac joint injection of anesthetic agents or steroids) was added to the list of approved ASC procedures for services performed on or after July 1, 2003 (CMS-1885-FC, 3/28/03). Therefore, when a therapeutic sacroiliac joint injection is administered to a Medicare beneficiary at an Ambulatory Surgical Center, it should be reported by the ASC as HCPCS code G0260. HCPCS code G0260, however, is not payable under the Medicare Physician Fee Schedule (MPFS). Physicians use CPCS code 27096 to bill for sacroiliac joint injection of anesthetic agents or steroids. Since HCPCS code 27096 was not on the list of Medicare approved ASC procedures, physicians may have been overpaid when performing this procedure in an ASC.

To rectify this problem, carriers have been instructed to add CPT code 27096 to their file of ASC approved procedures. Physicians who perform a sacroiliac joint injection of anesthetic agents or steroids (CPT code 27096) will now be reimbursed at the correct rate under the Medicare physician fee schedule. Please note that, for those Medicare carriers who did not make this change in a timely manner, there is a time lag between the effective date of July 1, 2003 and their new implementation date of February 2, 2004. Given this difference, claims that are submitted on or after the effective date for date of service, but prior to the implementation date, will be processed under the old rules. If this has affected your payments, you may wish to submit adjustment claims after February 2 in order to correct the payment.


Sacroiliac (SI) Joint Injections (CPT codes 27096 and G0260)

* Medicare does not have a National Coverage Determination (NCD) for Sacroiliac (SI) Joint Injections.

* Local Coverage Determinations (LCDs) which address sacroiliac injections exist and compliance with these LCDs is required where applicable. For state-specific LCD, refer to the LCD Availability Grid (Attachment F).

* For states with no LCDs, see the Wisconsin Physicians Services Novitas LCD for Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections (L34892) for coverage guidelines.

(IMPORTANT NOTE: After searching the Medicare Coverage Database, if no state LCD or Local Article is found, then use the above referenced policy.)

These are the only procedure where the CPT codes the ASC facility and the physician will bill may differ – codes are 27096 OR G0260.

27096 - Injection procedure for Sacroiliac Joint, Arthrography and/or Anesthetic/Steroid G0260 - Injection procedure for Sacroiliac Joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without Arthrography to be billed by ASC facilities ONLY.

* The ASC should use the G0260 code to bill SI Joint Injections to Medicare.

* The professional side (Physician claim) for SI Joint Injections should be billed to

Medicare with the 27096 code.

* The G0260 code is on the Medicare ASC list of covered procedures. The 27096 is NOT on the Medicare list of covered procedures. The physician and facility
CPT Codes are Copyrighted by the  claim coding will not match in this instance, but this coding is the correct way to code the procedure.

* The 27096 code is for use when the ASC facility is billing SI Joint Injections to ayors other than Medicare, unless they want the G-code instead. The facility would NOT bill the 27096 code to Medicare.

* Radiology codes – for SI Joint Injections performed with Arthrography, the 73542-TC code should be billed. The Fluoroscopy code to use with SI Joint Injections when Arthrography is not performed is code 77003-TC. These codes are billable provided the payor allows the billing of radiology services – which Medicare does NOT reimburse.

* The G-code and 27096 codes are for use billing SI Joint Injections performed with radiologic guidance. If the SI Joint Injection is performed without the use of radiologic guidance, neither the G-code nor the 27096 should be billed. SI Joint

Injections performed without the use of radiologic guidance should be billed using the 20610 code for an Injection into a Major Joint (which reimbursed at a low rate by Medicare). The 20610 code would be used by both the physician and the ASC
facility.

* For a Radiofrequency Treatment of the SI Joint, use code 64640. The most common diagnosis codes for SI Joint Injection procedures are 724.6 for Disorders of the Sacrum and 720.2 for Sacroiliitis. If an injection is administered in the Sacroiliac Joint without the use of Fluoroscopic guidance, report only the procedure code for the SI Joint Injection.

A formal radiologic report must be dictated when using the 73542 code for the Arthrography. Do not report code 77003-TC with code 73542-TC. The injection of contrast material is inclusive. This is a unilateral procedure; when a bilateral procedure is performed, bill it in a Bilateral manner by appending the -RT/-LT or -50 Bilateral Modifiers. Report CPT code 73542-TC for the Arthrography performed with the –TC Modifier.



SACROILIAC (SI) JOINT INJECTIONS

The sacroiliac (SI) joint is a diarthrodial synovial joint which is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain.

Indications

Sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint dysfunction.

Diagnostic and therapeutic injections of the SI joint would not likely be performed unless conservative therapy and noninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed.

Diagnostic SI joint blocks can be performed to determine whether it is the source of low back pain. Arthropathy (joint disease) is diagnosed through a double-comparative local anesthetic blockade of the joint by the intraarticular injection of a small volume of local anesthetics (2 — 3 ml) of different durations of actions. A positive  response should demonstrate initial pain relief of at least 75% and the ability to perform previously painful  maneuvers. Steroids may be injected in addition to the local anesthetic. Therapeutic SI joint injections of an anesthetic and/or steroid to block the joint for immediate, and potentially long lasting, pain relief are considered medically reasonable and necessary if it is determined that the SI joint is the source of the lower back pain.

Limitations

If previous diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for immediate, and potentially long lasting, pain relief have not effectively relieved the pain, further injections would not be considered medically necessary.

LIMITATIONS FOR ALL DIAGNOSTIC AND THERAPEUTIC PAIN MANAGEMENT SERVICES

1. Low back pain may also be associated with “myofascial pain syndrome” or a soft-tissue source of pain in which case no nerve root pathology exists, so interlaminar/translaminar, caudal, or transforaminal epidural injection would be ineffective. If the diagnosis is in question, the diagnosis of radiculopathy should be confirmed by electrophysiological studies, radiological studies, or a diagnostic transforaminal selective epidural/selective nerve root injection. A paravertebral joint/nerve or sacroiliac joint injection would also not be indicated for pain associated with “myofascial pain syndrome.”

2. Nerve blocks may be used for diagnostic and therapeutic purposes. Therapeutic blocks include the use of anesthetic, antispasmodic, and/or anti-inflammatory substances for the long-term control of pain. There is no role for a "series" of injections. Each injection should be individually evaluated for diagnostic/therapeutic clinical efficacy. If complete, but only temporary pain relief occurs after the injections, another type of treatment should be considered. (Note: Peripheral nerve blocks for the purpose of treating diabetic neuropathy is not supported by the current peer reviewed, published, evidence-based scientific literature nor by specialty society guidelines and is therefore not considered medically necessary)

3. Other interventional pain management procedures done on the same day as paravertebral facet joint blocks should be rare.

In certain circumstances a patient may present with both facet and sacroiliac problems. In this case, it is appropriate to perform both facet injections and SI injection at the same session assuming that these are therapeutic injections and that prior diagnostic injections (blocks) have demonstrated that both structures contribute to pain generation. The medical record must clearly support both procedures.

It is usually not appropriate to provide an interlaminar epidural/intrathecal injection, a transforaminal selective epidural (or selective nerve root injection), facet joint/nerve block, sacroiliac joint injection, lumbar sympathetic block or other nerve block on the same day. Therefore, only one of these procedures is allowed on a given day, unless conditions are met as described immediately above for paravertebral and sacroiliac joints or one of the following conditions occur and are documented in the medical record.

* If > 1 type of diagnostic injection is performed on the same day, the anesthetic response to the first injection must be assessed and demonstrate incomplete pain relief prior to proceeding with the additional injection. Otherwise it would be impossible to determine which injection resulted in pain relief

* Multiple pain generators are present and are clearly documented in a patient on anticoagulants, requiring the anticoagulants to be stopped for the injection(s)

4. Epidural steroids should be used only in the presence of radiculopathy unless the pain is discogenic in origin (see below for covered indications).

The standard of care for all transforaminal epidural injections for paravertebral facet joint/nerve injection and denervation, and sacroiliac joint injections requires that these procedures be performed under fluoroscopic or CT-guided imaging. Therefore, injections performed without imaging guidance will be considered inappropriate and not reasonable or necessary. The rationale for accepted medically necessary use of CT rather than fluoroscopy must be documented. Failure to obtain appropriate response to blind interlaminar or caudal epidurals may indicate improper delivery of the drug and/or presence of a pain generator, which is non-responsive to epidural injection.

Thus, subsequent epidural injections after a failed or inadequate response, if performed, should be under fluoroscopic visualization.

The following indications are covered for epidural steroid injections:

* Suspected radicular pain and/or neurogenic claudication

* Low back pain with significant imaging abnormalities indicating a discogenic origin for the pain (e.g, central disc herniation, severe degenerative disc disease, or central spinal stenosis). For a patient with low back pain, if imaging only shows a simple disc bulge or annular fissure, another indication must be met to justify the use of an epidural steroid injection

* Pain rating =3/10 with functional impairment in activities of daily living

* Failure of 6 weeks of conservative therapy (non-surgical, non-injection therapy) unless there is: Significant functional lossSevere pain unresponsive to medical management Inability to tolerate non-surgical, non-injection therapies due to comorbidities Prior successful epidural steroid injection for same condition

5. Specific to epidural and facet injections, sedation and/or Monitored Anesthesia Care (MAC) services are not generally required for pain management procedures. Anesthesia services will be denied (unless substantiated as being medically necessary) when reported with a pain management service. Modifier 59 will not override this edit.



ICD-10 Codes that Support Medical Necessity
   
    For Procedure Code 27096
 
    M08.1 Juvenile ankylosing spondylitis
    M12.551 Traumatic arthropathy, right hip
    M12.552 Traumatic arthropathy, left hip
    M12.559 Traumatic arthropathy, unspecified hip
    M12.851 Other specific arthropathies, not elsewhere classified, right hip
    M12.852 Other specific arthropathies, not elsewhere classified, left hip
    M12.859 Other specific arthropathies, not elsewhere classified, unspecified hip
    M13.851 Other specified arthritis, right hip
    M13.852 Other specified arthritis, left hip
    M13.859 Other specified arthritis, unspecified hip
    M16.0 Bilateral primary osteoarthritis of hip
    M16.10 Unilateral primary osteoarthritis, unspecified hip
    M16.11 Unilateral primary osteoarthritis, right hip
    M16.12 Unilateral primary osteoarthritis, left hip
    M16.2 Bilateral osteoarthritis resulting from hip dysplasia
    M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip
    M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip
    M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip
    M16.4 Bilateral post-traumatic osteoarthritis of hip
    M16.50 Unilateral post-traumatic osteoarthritis, unspecified hip
    M16.51 Unilateral post-traumatic osteoarthritis, right hip
    M16.52 Unilateral post-traumatic osteoarthritis, left hip
    M16.6 Other bilateral secondary osteoarthritis of hip
    M16.7 Other unilateral secondary osteoarthritis of hip
    M16.9 Osteoarthritis of hip, unspecified
    M25.551 Pain in right hip
    M25.552 Pain in left hip
    M25.559 Pain in unspecified hip
    M25.751 Osteophyte, right hip
    M25.752 Osteophyte, left hip
    M25.759 Osteophyte, unspecified hip
    M43.27 Fusion of spine, lumbosacral region
    M43.28 Fusion of spine, sacral and sacrococcygeal region
    M45.6 Ankylosing spondylitis lumbar region
    M45.7 Ankylosing spondylitis of lumbosacral region
    M45.8 Ankylosing spondylitis sacral and sacrococcygeal region
    M46.1 Sacroiliitis, not elsewhere classified
    M47.26 Other spondylosis with radiculopathy, lumbar region
    M47.27 Other spondylosis with radiculopathy, lumbosacral region
    M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
    M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
    M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
    M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
    M47.896 Other spondylosis, lumbar region
    M47.897 Other spondylosis, lumbosacral region
    M47.898 Other spondylosis, sacral and sacrococcygeal region
    M48.06 Spinal stenosis, lumbar region
    M48.07 Spinal stenosis, lumbosacral region
    M48.8X1 Other specified spondylopathies, occipito-atlanto-axial region
    M48.8X2 Other specified spondylopathies, cervical region
    M48.8X3 Other specified spondylopathies, cervicothoracic region
    M48.8X4 Other specified spondylopathies, thoracic region
    M48.8X5 Other specified spondylopathies, thoracolumbar region
    M48.8X6 Other specified spondylopathies, lumbar region
    M48.8X7 Other specified spondylopathies, lumbosacral region
    M48.8X8 Other specified spondylopathies, sacral and sacrococcygeal region
    M48.8X9 Other specified spondylopathies, site unspecified
    M51.14 Intervertebral disc disorders with radiculopathy, thoracic region
    M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region
    M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
    M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
    M53.2X7 Spinal instabilities, lumbosacral region
    M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
    M53.3 Sacrococcygeal disorders, not elsewhere classified
    M53.86 Other specified dorsopathies, lumbar region
    M53.87 Other specified dorsopathies, lumbosacral region
    M53.88 Other specified dorsopathies, sacral and sacrococcygeal region
    M54.14 Radiculopathy, thoracic region
    M54.15 Radiculopathy, thoracolumbar region
    M54.16 Radiculopathy, lumbar region
    M54.17 Radiculopathy, lumbosacral region
    M54.30 Sciatica, unspecified side
    M54.31 Sciatica, right side
    M54.40 Lumbago with sciatica, unspecified side
    M54.41 Lumbago with sciatica, right side
    M54.42 Lumbago with sciatica, left side
    M54.5 Low back pain
    M70.60 Trochanteric bursitis, unspecified hip
    M70.61 Trochanteric bursitis, right hip
    M70.62 Trochanteric bursitis, left hip
    M70.70 Other bursitis of hip, unspecified hip
    M70.71 Other bursitis of hip, right hip
    M70.72 Other bursitis of hip, left hip
    M76.00 Gluteal tendinitis, unspecified hip
    M76.01 Gluteal tendinitis, right hip
    M76.02 Gluteal tendinitis, left hip
    M76.10 Psoas tendinitis, unspecified hip
    M76.11 Psoas tendinitis, right hip
    M76.12 Psoas tendinitis, left hip
    M76.20 Iliac crest spur, unspecified hip
    M76.21 Iliac crest spur, right hip
    M76.22 Iliac crest spur, left hip
    M76.30 Iliotibial band syndrome, unspecified leg
    M76.31 Iliotibial band syndrome, right leg
    M76.32 Iliotibial band syndrome, left leg
    M99.04 Segmental and somatic dysfunction of sacral region
    M99.05 Segmental and somatic dysfunction of pelvic region
    M99.23 Subluxation stenosis of neural canal of lumbar region
    M99.33 Osseous stenosis of neural canal of lumbar region
    M99.43 Connective tissue stenosis of neural canal of lumbar region
    M99.53 Intervertebral disc stenosis of neural canal of lumbar region
    M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region
    M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region
    Q76.2 Congenital spondylolisthesis
    S33.6XXA Sprain of sacroiliac joint, initial encounter
    S33.6XXD Sprain of sacroiliac joint, subsequent encounter
    S33.6XXS Sprain of sacroiliac joint, sequela
    S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter
    S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent encounter
    S33.8XXS Sprain of other parts of lumbar spine and pelvis, sequela
    S33.9XXA Sprain of unspecified parts of lumbar spine and pelvis, initial encounter
    S33.9XXD Sprain of unspecified parts of lumbar spine and pelvis, subsequent encounter
    S33.9XXS Sprain of unspecified parts of lumbar spine and pelvis, sequela

Based on review of the case file the following is noted:


* ISSUE IN DISPUTE: Provider seeking $549.33 in remuneration for G0260-LT Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography, performed 11/21/2014.


* Claims Administrator reimbursement rational: “Service not paid under OPPS.”


* Pursuant to Labor Code section 5307.1(g)(2), the Administrative Director of the Division of Workers’ Compensation orders that Title 8, California Code of Regulations, sections 9789.30 and 9789.31, pertaining to Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule in the Official Medical Fee Schedule, is amended to conform to CMS’ hospital outpatient prospective payment system (OPPS). The Administrative Director incorporates by reference, the Centers for Medicare and Medicaid Services' (CMS) Hospital Outpatient Prospective Payment System (OPPS) certain addenda published in the Federal Register notices announcing revisions in the Medicare payment rates. The adopted payment system addenda by date of service are found in the Title 8, California Code of Regulations, and Section 9789.39(b). Based on the adoption of the CMS hospital outpatient prospective payment system (OPPS), CMS coding guidelines and the hospital outpatient prospective payment system (OPPS) were referenced during the review of this Independent Bill Review (IBR) case


* Based on the provider type, the reimbursement for services is calculated on the Centers for Medicare and Medicaid Services (CMS) Outpatient Prospective Payment System (OPPS). Procedures are assigned APC weights and "Proposed Payment Status Indicators." The surgical HCPCS code G0260 has an assigned indicator of "T". The "T" indicator definition is "Significant procedure, multiple procedure reduction applies" and qualifies for separate APC payment


* UB-04 reflects one line item billed as G0260.


* G0260 code and 27096 codes are for use billing SI Joint Injections performed with radiologic guidance.


* The surgical Procedure  code 27096 has an assigned indicator of “B”. The B indicator definition is “May be paid by fiscal intermediaries/MACs when submitted on a different bill type” and is not paid under OPPS.

* The Operative Report documented “fluoroscopic guidance to the inferior aspect of the left SI jont.”

* A review of the Addendum AA, ASC Covered Surgical Procedures for CY 2014 does not list HCPCS code 27096, but it does list G0260. Addendum B for CY 2014 does not list an APC Relative weight for procedure code 27096 as this codes in not reimbursable under OPPS. However, a relative weight is listed for HCPCS G0260. Therefore, the Provider correctly submitted HCPCS code G0260 for billing an OPPS anesthetic injection to sacroiliac joint and reimbursement is warranted for the ASC payment rate for HCPCS G0260.

* Based on the aforementioned documentation and guidelines, reimbursement is indicated for G0260.