CSHCN 2008 >24.3.20.5 Reimbursement for Immunizations (Vaccines/Toxoids)

Claims must be submitted with the appropriate vaccine/toxoid procedure code and the appropriate administration procedure code.

When providers obtain vaccines/toxoids from TVFC, the CSHCN Services Program reimburses only the administration fee, which providers may bill on a CMS-1500 claim form with the appropriate CSHCN Services Program provider identifier. Providers may bill only administration fees for vaccines obtained from TVFC.

If the CSHCN Services Program client is immunized during an initial or follow-up office visit for a medical condition, the visit is reimbursed, in addition to the immunization administration fee, when an appropriate medical diagnosis is referenced in Block 24D of the CMS-1500 claim form. If the CSHCN Services Program client visit is only for immunizations, an office visit must not be billed in addition to the immunization administration procedure code. One of the following immunization only diagnosis codes must be referenced on the claim:


Diagnosis Code	Description
V035	Need for prophylactic vaccination and inoculation against diphtheria alone
V036	Need for prophylactic vaccination and inoculation against pertussis alone
V037	Need for prophylactic vaccination with tetanus toxoid alone
V0381	Need for prophylactic vaccination and inoculation against hemophilus influenza, type B [HIB]
V0382	Need for prophylactic vaccination and inoculation against streptococcus pneumoniae [pneumococcus]
V0389	Need for prophylactic vaccination and inoculation against other specified single bacterial disease
V039	Need for prophylactic vaccination and inoculation against unspecified single bacterial disease
V040	Need for prophylactic vaccination and inoculation against poliomyelitis
V041	Need for prophylactic vaccination and inoculation against smallpox
V042	Need for prophylactic vaccination and inoculation against measles alone
V043	Need for prophylactic vaccination and inoculation against rubella alone
V046	Need for prophylactic vaccination and inoculation against mumps alone
V047	Need for prophylactic vaccination and inoculation against common cold
V048	Need for prophylactic vaccination and other inoculation against viral diseases
V0481	Need for prophylactic vaccination and inoculation, influenza
V0482	Need for prophylactic vaccination and inoculation, respiratory synctial virus (RSV)
V0489	Need for prophylactic vaccination and inoculation, other viral diseases
V050	Need for prophylactic vaccination and inoculation against arthropod-borne viral encephalitis
V051	Need for prophylactic vaccination and inoculation against other arthropod-borne viral diseases
V052	Need for prophylactic vaccination and inoculation against leishmaniasis
V053	Need for prophylactic vaccination and inoculation against viral hepatitis
V054	Need for prophylactic vaccination and inoculation against varicella
V058	Need for prophylactic vaccination and inoculation against other specified disease
V059	Need for prophylactic vaccination and inoculation against unspecified single disease

Providers who purchase the vaccine/toxoid may be reimbursed either the lower of the billed amount, the amount allowed by the Texas Medicaid Program, or the maximum fee established by the CSHCN Services Program for the vaccine or toxoid product.