Bacillus Calmette-Guérin (BCG)

Refer to: Subsection 8.2.9, "Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of Bladder Cancer" in this handbook.

Hepatitis A and B

90632

90633*

90636*

90723*

90743

90744*

90746

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.

Texas Medicaid-eligible clients residing in a private (nonstate) institution for persons with intellectual disabilities (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 in clients of an ICF-MR (private) facility.

When the hepatitis B vaccine is provided to clients 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 (procedure code 90636) is indicated for clients who are 18 years of age and 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

90647*

90648*

Human Papilloma (HPV)

90649*

90650

Influenza

90654

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 declared available through the TVFC. 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.

MMR and MMRV

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 and older.

Pneumococcal and Meningococcal

90669

90670*

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

•Clients 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 five 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 who are 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

90696*

90698*

90700*

90702*

90703

90715*

90718*

90721*

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*