Bacillus Calmette-Guérin (BCG)

Refer to: Subsection 6.3.7, "Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of Bladder Cancer" in this handbook.

Diphtheria

90696

90698*

90700*

90702*

Hepatitis A and B

90632*

90633*

90636

90740*

90743

90744*

90746*

90747

90748*

Procedure codes 90740, 90744, and 90747: For clients who are birth through 18 years of age, the state-mandated administration of the hepatitis B vaccine to newborns before discharge from the hospital has been established as the accepted standard of care and will not be considered as a reason to up-code to a different diagnosis-related group (DRG). The administration of the hepatitis B vaccine to newborns is included in the DRG payment and will not be reimbursed separately.

Mentally retarded Texas Medicaid-eligible individuals residing in a private (nonstate) institution for persons with mental retardation (ICF-MR), are classified as at a continuing high risk for hepatitis B with an ongoing exposure potential. When provided by and billed by the attending physician, Texas Medicaid may reimburse the hepatitis B vaccine for all inpatients of an ICF-MR (private) facility.

When the hepatitis B vaccine is provided to recipients with end-stage renal disease who are directly exposed to the virus, the administration fee and the vaccine may be reimbursed in addition to the dialysis services.

Administration of the hepatitis A and B vaccine is indicated for persons who are 18 years of age or older and at risk for both hepatitis A and hepatitis B infections. Providers are expected to follow the ACIP recommendations for administration.

Hepatitis B Immune Globulin

90371

96372

96374

J1571

J1573

Providers must document in the client's medical record the indication for the immunoglobulin. These records are subject to retrospective review to determine appropriate utilization of and reimbursement for this service.

Intramuscular hepatitis B immune globulin (HBIg) may be reimbursed when medically necessary to provide coverage for acute exposure to the hepatitis B virus. HBIg is not provided through TVFC.

Procedure codes 90371, J1571, and J1573 must be billed with diagnosis code V0179.

Only one HBIg procedure code will be paid if billed with the same date of service by the same provider as any other HBIg procedure code.

Procedure codes 96372 and 96374 may be reimbursed for HBIg administration.

Hib

90645

90646

90647

90648*

Human Papilloma (HPV)

90649*

Influenza

90655*

90656*

90657*

90658*

90660*

Influenza vaccine is a benefit of Texas Medicaid for high-risk clients who are not covered by THSteps or TVFC or when the vaccine is not available through the TVFC. TVFC supplies the vaccine only from late September through January. Providers are expected to follow ACIP recommendations relating to prevention and control of influenza.

Texas Medicaid considers the influenza season in the United States to be October through the end of May.

H1N1 Influenza

90663

Texas Medicaid reimburses the administration fee for up to two doses per client, any provider, when the doses are given on different dates following the ACIP guidelines.

Administration of the H1N1 flu vaccine is reimbursed separately from a THSteps visit or office visit.

Mumps, Measles, Rubella, and MMR

90704

90705

90706

90707*

90710*

The MMR vaccine (procedure code 90707) is a benefit of Texas Medicaid for high-risk females of child-bearing age who are 21 years of age or older.

Pneumococcal and Meningococcal

90669*

90732*

90733

90734*

The pneumococcal polysaccharide vaccine (procedure code 90732) is a benefit for the following individuals:

•Texas Medicaid clients not covered by the THSteps or TVFC programs

•High-risk clients who are 2 years of age or older (when medically necessary)

•Individuals who have long-term health problems that lower the body's resistance to infection

The initial pneumococcal polysaccharide vaccine is limited to one per client per lifetime. For high-risk clients, revaccination is recommended once in a lifetime 5 years after the initial dose. Revaccination after a second dose is not a benefit of Texas Medicaid.

Pneumococcal polysaccharide vaccine is not recommended for children birth through 23 months of age.

Providers are expected to follow the ACIP recommendations for administrations.

Poliovirus (IPV)

90713*

Rotavirus

90680*

90681

Tetanus and Diphtheria

90703

90714*

90715*

90718

90721

90723*

Note: The FDA has approved Boostrix (Tetanus Toxoid, Reduced Diptheria Toxoid, and Acellular Pertussis Vaccine [Tdap], Adsorbed) for use in adults who are 19 through 64 years of age. Previously, Boostrix was approved only for patients who are 10 through 18 years of age. Since October 2005, ACIP has recommended the administration of a single dose of Tdap for adults who are 19 through 64 years of age to replace the next booster dose of tetanus and diphtheria toxoids vaccine (Td). For complete prescribing information, refer to the Boostrix package insert, located at www.fda.gov/Cber/label/boostrixLB.pdf

Tetanus Immune Globulin

J1670

Tetanus immune globulin (TIG) (procedure code J1670) provides a passive immunity for injuries that are over 24 hours old, for injuries that are extensively contaminated, and for clients who have had fewer than 2 tetanus toxoid injections in a lifetime. Therefore, both procedure codes 90703 and J1670 can be given on the same day, for the same injury event.

After an acute penetrating or invasive injury, prevention of tetanus is accomplished through appropriate wound cleansing and debridement and the administration of human TIG, when indicated. TIG is indicated for prophylaxis against tetanus following an acute penetrating or invasive injury in a client whose immunization is incomplete or uncertain. Providers are expected to follow the ACIP recommendations for administration.

TIG injections will be reimbursed for injuries, such as puncture wounds, burns, or abrasions.

Unlisted

90749

Varicella Virus

90716