|
6.3.58.1 Benefits and Limitations
RSV prophylaxis is not reimbursed for dates of service outside the RSV season.
Exception: RSV prophylaxis may be reimbursed for 2 weeks preceding the start of the RSV season for hospitalized infants determined to be at risk of severe RSV disease in September.
RSV prophylaxis injections given during an inpatient hospital stay are considered included in the hospital DRG and are not separately reimbursed.
RSV prophylaxis is not reimbursed for Medicaid clients 24 months of age or older at the start of the RSV season in Texas.
CCP may consider reimbursement for the intramuscular version of the RSV prophylaxis when billed with procedure code 90378. RSV prophylaxis is provided in single use vials and must be billed per milligram (mg). If different size vials (e.g., 50 mg vial and 100 mg vial) are required for the appropriate dosage on the same date of service, providers must bill each vial separately on the same claim and include the appropriate National Drug Code (NDC) for each detail.
Providers are required to maintain accurate records of the total number of units given and the total number of units purchased, administered, and wasted for each client. If billing waste, the total number of units billed must include the number of units wasted. Texas Medicaid reimburses providers for waste only if a partial vial is actually wasted and not if the partial vial is used for another patient.
Example: If 180 mg is administered to a client and 20 mg is wasted, 200 services/units must be billed, not 4 services/units.
Providers may not bill Texas Medicaid if the RSV prophylaxis was obtained through the Vendor Drug Program (VDP), however, providers may be reimbursed for administering the drug.
RSV prophylaxis medications are covered in the home, office, or outpatient settings.
|
