Increased Medicaid Fee Amounts For Vaccines

The Medicaid fiscal agent completed required coding for vaccine administration codes CPT 90460, CPT 90471, and CPT 90472 for the Affordable Care Act enhanced rate.  Physicians must bill the vaccine product code and the vaccine administration code to receive the full reimbursement allowed by the Affordable Care Act Primary Care rate increase.

The federal rule does not allow for reimbursement of procedure code CPT 90461.  Medicaid will not reimburse procedure codes CPT 90473 and CPT 90474 at this time, as no Medicaid covered vaccines for recipients ages 19-20 are administered via the intranasal or oral route.  Procedure code CPT 90460 includes all routes of administration, and Medicaid will reimburse up to five units of CPT 90460 per claim line, so providers may bill this code for recipients ages 0-18 as stated below.

Procedure Code CPT 90460

Medicaid will reimburse procedure code CPT 90460 along with the appropriate vaccine product code for each individual vaccine administration product provided to recipients ages 0-18.  Medicaid will reimburse up to five units of procedure code CPT 90460 per day.  Physicians should not bill 90460 for each separate component (antigen) in a single product.  This code is valid for any route of administration including intramuscular, subcutaneous, oral, and intranasal.

Procedure codes CPT 90471 and CPT 90472

Medicaid will reimburse vaccine administration procedure codes CPT 90471 HA and CPT 90472 HA for recipients age 19-20, along with the appropriate vaccine product code. 

Physicians must append modifier HA to these codes in order to receive the Affordable Care Act primary care enhanced reimbursement.  Medicaid will reimburse up to one unit of procedure code CPT 90471 HA per day, and a maximum of 4 units per day for CPT 90472 HA.

Retroactive Reimbursement

Since the ACA rates are effective January 1, 2013, providers will have the option to submit claims for vaccination administration codes (CPT 90460, CPT 90471, and CPT 90472) retroactively to January 1, 2013.  Effective immediately Medicaid will reimburse eligible physicians for the vaccine administration codes for dates of service on or after January 1, 2013.

During the one-time reprocessing scheduled for June of 2013, claims that were not previously billed to include the vaccine administration codes (CPT 90460, CPT 90471, and CPT 90472) will not be reimbursed for these codes via the reprocessing.  In order to receive the increased reimbursement for the vaccine administration codes, physicians will need to resubmit vaccination claims, or file separate claims for the administration codes for dates of service beginning January 1, 2013.