North Carolina Medicaid - Billing Guidelines for Vaccines

1. Effective with date of service July 1, 2011, the ONLY immunization administration codes covered for Medicaid recipients in the Health Check age range, 0 through 20 years of age, are CPT codes 90471 through 90474.

2. Claims billed with CPT immunization administration codes 90460 and 90461 (effective for dates of service on and after January 1, 2011, for Medicaid recipients through 18 years of age) on and after July 1, 2011, will deny.

3. Append modifier EP to all immunization administration codes billed for Medicaid recipients in the Health Check age range, 0 through 20 years of age.

4. Do NOT append the EP modifier to the vaccine CPT codes.

5. All of the units billed for CPT codes 90471EP, 90472EP, 90473EP, and 90474EP must be billed on ONE detail to avoid duplicate audit denials. Currently, 90474EP cannot be billed with 90473EP because there are no two oral/intranasal vaccines that would be given to a recipient. Only one unit of either 90473EP or 90474EP is allowed.

6. CPT vaccine codes for the vaccines administered must be reported or billed, as appropriate, even if administration codes are not being billed.

7. For Medicaid recipients 21 years of age and older (above the Health Check age range), the immunization administration codes have not changed. Bill the series of CPT codes 90471 through 90474 without the EP modifier.

Please refer to individual bulletin articles on specific vaccines for additional billing guidelines.

Please visit North Carolina Medicaid Coverage for Preventive examination and Screening services.

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