TMPPM 2010 >6.3.31 Immunizations for Clients Who Are 21 Years of Age or Older

Vaccines and toxoids may be reimbursed through Texas Medicaid at a fee determined by HHSC when the vaccine is medically necessary.

The following immunizations are identified and recommended by the ACIP as medically-necessary for clients who are 21 years of age or older (this list is not all-inclusive):


Immunization Procedure Codes
BCG
Refer to: Subsection 6.3.7, "Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of Bladder Cancer" in this handbook.
Hepatitis A
90632
Administration of the hepatitis A vaccine is indicated for at-risk adults according to ACIP recommendations. Providers are expected to follow the ACIP recommendations for administration.
Hepatitis B
90740	90746	90747
Administration of the hepatitis B vaccine is indicated for at-risk adults according to ACIP recommendations. Providers are expected to follow the ACIP recommendations for administration. Mentally retarded Texas Medicaid-eligible individuals who reside in a private (nonstate) 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.
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 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.
Hepatitis A and B
90636
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.
Human Papilloma (HPV)
90649*
The HPV vaccine is a benefit of Texas Medicaid for females who are 21 years of age through 26 years of age. Providers are expected to follow the ACIP recommendations for administration.
Influenza
90655	90656	90657	90658	90663
Influenza vaccine is a benefit of Texas Medicaid for high-risk clients. 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. The optimal time to receive influenza vaccine is October through March. The vaccine may be administered one time per influenza season.
Measles, Mumps, Rubella Vaccine (MMR)
90707
MMR vaccine is a benefit of Texas Medicaid for high-risk females of child-bearing age who are 21 years of age or older. Providers are expected to follow the ACIP recommendations for administration.
Pneumococcal Polysaccharide Vaccine
90732
Pneumococcal polysaccharide vaccine is indicated for individuals who have long-term health problems that lower the body's resistance to infection. Providers are expected to follow the ACIP recommendations for administration. The initial pneumococcal polysaccharide vaccine is limited to one per client per lifetime. Revaccination is recommended 5 years (not interpreted to mean every 5 years) after the initial dose for high-risk individuals. Providers are expected to follow the ACIP recommendations for administration. Revaccination after a second dose is not reimbursed.
Tetanus
90703	90714	90715	90718
Tetanus toxoid-containing vaccines are indicated to prevent tetanus. Clients who are 19 through 64 years of age and who require a tetanus toxoid-containing vaccine as part of wound management should receive combination antigen Tetanus, Diptheria, and Pertussis (Tdap) vaccine instead of the single antigen Tetanus-diptheria (Td) vaccine if they previously have not received Tdap.
Tetanus Immune Globulin
J1670
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. 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.

The specific diagnosis necessitating the vaccine or toxoid is required when billing the administration fee procedure code in combination with the appropriate vaccine procedure code.