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.