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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.36 Immunizations for Clients Birth through 20 Years of Age : 8.2.36.2 Vaccine and Toxoid Procedure Codes

8.2.36.2
The following vaccine and toxoid procedure codes may be reimbursed for Texas Medicaid clients who are birth through 20 years of age:
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.
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.
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.
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.
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.
* Indicates a vaccine or toxoid distributed through TVFC. Vaccines and toxoids available through TVFC for clients who are birth through 18 years of age will not be reimbursed through Texas Medicaid. These vaccines and toxoids will be processed as informational.

Texas Medicaid & Healthcare Partnership
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