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Benefit Criteria to Change for CSHCN Vaccines

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Effective for dates of service on or after January 1, 2021, vaccine benefit criteria will change for the Children with Special Health Care Needs (CSHCN) Services Program.

Reimbursement

For clients who are 18 years of age and older, procedure code 90739 may be reimbursed to the following:

  • Physician assistant, nurse practitioner, clinical nurse specialist, physician, and pharmacy providers for services rendered in the office setting
  • Physician assistant, nurse practitioner, clinical nurse specialist, and physician providers in the home and other settings
  • Physician and hospital providers in the outpatient hospital setting

For clients who are 50 years of age and older, procedure code 90750 may be reimbursed to the following:

  • Physician assistant, nurse practitioner, clinical nurse specialist, physician, and pharmacy providers for services rendered in the office setting
  • Physician assistant, nurse practitioner, clinical nurse specialist, and physician providers in the home and other settings
  • Physician and hospital providers in the outpatient hospital setting

The following procedure codes may be reimbursed to physician assistant, nurse practitioner, clinical nurse specialist, and physician providers for services rendered in the home setting:

Procedure Codes

90620

90621

90651

90661

90674

90756

 

The following procedure codes may be reimbursed to physician providers for services rendered in the outpatient hospital setting:

Procedure Codes

90287

90460

90461

90471

90472

90473

90474

90585

90620

90621

90630

90632

90633

90636

90647

90648

90650

90651

90654

90655

90656

90657

90658

90660

90661

90662

90670

90672

90673

90674

90680

90681

90682

90685

90686

90687

90688

90696

90698

90700

90702

90707

90710

90713

90714

90715

90716

90723

90732

90733

90734

90736

90740

90743

90744

90746

90747

90748

90749

90756

96372

96374

 

The following procedure codes will be limited to three per rolling year, for any procedure, with any provider:

Procedure Codes

90630

90654

90655

90656

90657

90658

90660

90661

90662

90672

90673

90674

90682

90685

90686

90687

90688

90756

Procedure code 90670 will be limited to one per day for clients who are birth through five years of age, same procedure, any provider, and to one per lifetime for clients who are age six and older.

Procedure code 90698 will be a benefit for clients of all ages.

Procedure codes 90740, 90747, 96372, and 96374 may be reimbursed for pharmacist and pharmacy providers for services rendered in the office setting.

Procedure code 90756 may be reimbursed to physician assistant, nurse practitioner, clinical nurse specialist, and physician providers for services rendered in the home setting. 

Procedure codes 96372 and 96374 will be limited to one procedure per day, same procedure, same provider; and may be reimbursed to physician assistant, nurse practitioner, clinical nurse specialist, and physician providers for services rendered in the home and other settings.

Procedure code 90644 will no longer be a benefit.

The following procedure codes will no longer be reimbursed to federally qualified health center (FQHC) providers for services rendered in the office setting:

Procedure Codes

90620

90621

90651

90661

90674

90756

The following procedure codes will no longer be reimbursed to FQHC providers for services rendered in the home setting:

Procedure Codes

90660

90686

90688

90696

90736

Procedure codes 90740 and 90747 will no longer be reimbursed to nephrology (hemodialysis, renal dialysis) and renal dialysis facility providers for services rendered in the outpatient hospital setting.

Vaccine Administration

Covered Age Ranges for Vaccine Administration

The age ranges for vaccine administration are listed in the following table:

Procedure Code

Age Range

90460

0-18 years

90461

0-18 years

90471

All ages

90472

All ages

90473

All ages

90474

All ages

96372

All ages

96374

All ages

Components

Note: In the table below, * Indicates a vaccine distributed through Texas Vaccines for Children Program (TVFC).

The following procedure codes may be reimbursed for vaccines:

Procedure Code

Age Range

Number of Recognized Components

90287

All ages

1

90585

All ages

1

90619

19 years of age and older

1

90620*

All ages

1

90621*

All ages

1

90632*

Birth through 20 years of age

1

90633*

Birth through 20 years of age

2

90636*

All ages

2

90647*

All ages

1

90648*

All ages

1

90650

9 years of age through 26 years of age

1

90651*

All ages

1

90670*

All ages

1

90680*

Birth through 11 months of age

1

90681*

All ages

1

90696*

4 years of age through 6 years of age

4

90698*

All ages

5

90700*

Birth through 6 years of age

3

90702*

Birth through 6 years of age

2

90707*

All ages

3

90710*

All ages

4

90713*

All ages

1

90714*

7 years of age and older

2

90715*

7 years of age and older

3

90716*

All ages

1

90723*

All ages

5

90732*

2 years of age and older

1

90733*

All ages

1

90734*

All ages

1

90736

60 years of age and older

1

90739

18 years of age and older

1

90740

All ages

1

90743*

All ages

1

90744*

All ages

1

90746*

All ages

1

90747

All ages

1

90748

All ages

2

90749

All ages

1

90750

50 years of age and older

1

Influenza Vaccines

The Advisory Committee on Immunization Practices (ACIP) reviews the composition of influenza vaccines annually and frequently makes updates to their recommendations. Providers should refer to the Centers for Disease Control and Prevention (CDC) website for current recommendations.

Providers should refer to the TVFC website for the most up-to-date list of the influenza vaccines that TVFC is distributing for clients and their age group for the current flu season.

Reimbursement for influenza vaccines is limited to three occurrences per one rolling year. Claims submitted for any influenza vaccine beyond three occurrences in a rolling year will be denied.

The age ranges for influenza vaccines are listed in the following table:

Procedure Code

Age Range

90630

All ages

90654

All ages

90655

6 months of age through 35 months of age

90656

3 years of age and older

90657

6 months of age through 35 months of age

90658

3 years of age and older

90660

All ages

90661

All ages

90662

All ages

90672

All ages

90673

All ages

90674

All ages

90682

18 years of age and older

90685

6 months of age through 35 months of age

90686

All ages

90687

6 months of age through 35 months of age

90688

All ages

90756

4 years of age and older

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.