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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 5. THSteps Medical : 5.3 Services, Benefits, Limitations, and Prior Authorization : 5.3.9 Mandated Components : 5.3.9.3 Immunizations

5.3.9.3
Providers must screen the immunization status at every medical checkup. The necessary vaccines and toxoids must be administered at the time of the checkup unless medically contraindicated or because of parent's reasons of conscience including religious beliefs.
Vaccines and toxoids must be administered according to the current ACIP “Recommended Childhood and Adolescent Immunization Schedule - United States.” Providers must not refer clients to the local health department or other entity for immunization administration.
Vaccines and toxoids must be obtained from TVFC for clients who are birth through 18 years of age. Vaccines that are identified as being distributed through TVFC are not reimbursed separately.
The specific diagnosis necessitating the vaccine and toxoid is required when billing with the following administration procedure codes in combination with an appropriate vaccine/toxoid procedure code:.
Diagnosis code V202 may be used unless a more specific diagnosis code is appropriate.
Procedure codes 90460 and 90461 are benefits for services rendered to clients who are birth through 18 years of age when counseling is provided for the immunization administered.
Procedure codes 90471, 90472, 90473, and 90474 are benefits for services rendered to clients of any age when counseling is not provided for the immunization administered.
The following vaccines and toxoids are a benefit of Texas Medicaid:
Number of Components**
Number of Components**
Providers may use the state-defined modifier U1 in addition to the associated administered vaccine procedure code for clients who are birth through 18 years of age and the vaccine was unavailable through TVFC.
State-defined modifier: Vaccine(s)/toxoid(s) privately purchased by provider when TVFC vaccine/toxoid is unavailable
Note:
“Unavailable” is defined as a new vaccine approved by the Advisory Committee on Immunization Practices (ACIP) that has not been negotiated or added to a TVFC contract, funding for new vaccine that has not been established by TVFC, or national supply or distribution issues. Providers will be informed if a vaccine meets the definition of ‘not available’ from TVFC and when the provider's privately purchased vaccine may be billed with modifier U1.
Modifier U1 may not be used for failure to enroll in TVFC, maintain sufficient TVFC vaccine/toxoid inventory, or clients who are 19 through 20 years of age.
Each vaccine or toxoid and its administration must be submitted on the claim in the following sequence: the vaccine procedure code immediately followed by the applicable immunization administration procedure code(s). All of the immunization administration procedure codes that correspond to a single vaccine or toxoid procedure code must be submitted on the same claim as the vaccine or toxoid procedure code.
Each vaccine or toxoid procedure code must be submitted with the appropriate “administration with counseling” procedure code(s) (procedure codes 90460 and 90461) or the most appropriate “administration without counseling” procedure code (procedure code 90471, 90472, 90473, or 90474). If an “administration with counseling” procedure code is submitted with an “administration without counseling” procedure code for the same vaccine or toxoid, the administration of the vaccine or toxoid will be denied.
Administration With Counseling
Providers must submit claims for immunization administration procedure codes 90460 or 90461 based on the number of components per vaccine. Providers must specify the number of components per vaccine by billing 90460 and 90461 as defined by the procedure code descriptions:
Procedure code 90461 will be denied if procedure code 90460 has not been submitted on the same claim for the same vaccine or toxoid.
The necessary counseling that is conducted by a physician or other qualified health-care professional must be documented in the client's medical record.
The following is an example of how to submit claims for immunization administration procedure codes when counseling is provided:
Note:
The term “components” refers to the number of antigens that prevent disease(s) caused by one organism. Combination vaccines are those that contain multiple vaccine components.
Administration Without Counseling
Procedure codes 90471, 90472, 90473, and 90474 may be reimbursed per vaccine based on the route of administration.
The following is an example of how to submit claims for injection administration procedure codes when counseling is not provided:
5.3.9.3.1 Vaccine Information Statement (VIS)
A VIS is required by federal mandate to inform parents and vaccine recipients of the risks and benefits of the vaccine they are about to receive. Not only is it important to explain the risks and benefits before a vaccine is administered, it is also important that providers use the most current forms available. For more about immunizations, vaccine-preventable diseases, or literature and forms, providers can call the DSHS Immunization Branch at 1-800-252-9152 or review information at www.dshs.state.tx.us/immunize.
Refer to:
Appendix B: Immunizations in this handbook.
Form CH.39, “TVFC Provider Enrollment (3 Pages)” in Appendix A, “THSteps Forms,” in this handbook for more information on enrolling as a TVFC provider.
The THSteps online education module “Immunizations,” located on the THSteps website at www.txhealthsteps.com, for more information about immunizations.

Texas Medicaid & Healthcare Partnership
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