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Benefit Criteria to Change for Vaccine Services Effective September 1, 2022

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after September 1, 2022, vaccine services benefits will change for Texas Medicaid.

The following procedure code will become a benefit for vaccine services:

Procedure Code

Age Range

Number of Recognized Components

90759

18 years and older

1

The following procedure codes will no longer be a benefit for vaccine services because of the discontinuation of the associated vaccine or inappropriate utilization:

Procedure Codes

90644

90650

90733

90748

90749

 

Texas Vaccines for Children (TVFC) Providers

Procedure code 90461 may not be billed by Texas Vaccines for Children (TVFC) providers when administering TVFC-eligible vaccines under the TVFC program.

Nephrology and Renal Dialysis Facility Providers

The following procedure codes will be benefits for nephrology providers in the office setting and nephrology providers and renal dialysis facilities in the outpatient hospital setting:

Procedure Codes

Category

90371, J1571, J1573

Hepatitis B immune globulin

90740, 90747

Hepatitis B vaccine for immunocompromised/dialysis patients

90630, 90654, 90655, 90656, 90657, 90658, 90661, 90662, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90756

Influenza vaccine

90670, 90671, 90677, 90732

Pneumococcal vaccine

90460, 90471, 90472

Vaccine administration

Federally Qualified Health Center (FQHC) Providers

Federally qualified health center (FQHC) providers will no longer be reimbursed for services rendered in the home setting for the following procedure codes:

Procedure Codes

90460

90461

90471

90472

90473

90474

90620

90621

90630

90632

90633

90636

90647

90648

90651

90654

90655

90656

90657

90658

90660

90661

90662

90670

90672

90680

90681

90685

90686

90687

90688

90696

90698

90700

90702

90707

90710

90713

90714

90715

90716

90723

90732

90734

90736

90740

90743

90744

90746

90747

90750

90756

   

Covered Age Ranges for Vaccines and Vaccine Administration

The age range limitations will be updated for the following procedure codes:

Procedure Code

Age Range

90473

All ages

90474

All ages

90620

10 years or older

90621

10 years or older

90630

6 months or older

90632

18 years or older

90633

Birth through 18 years

90636

19 years or older

90647

6 weeks through 18 years

90648

6 weeks or older

90651

9 years through 45 years

90654

6 months or older

90660

6 months through 20 years

90661

6 months or older

90662

65 years or older

90670

2 months or older

90672

2 years through 49 years

90673

6 months or older

90674

6 months or older

90680

Birth through 8 months

90681

Birth through 8 months

90698

Birth through 5 years

90707

1 year or older

90710

1 year through 12 years

90713

2 months or older

90716

1 year or older

90723

6 weeks through 6 years

90732

2 years or older

90734

2 months through 55 years

90740

20 years or older

90743

11 years through 17 years

90744

Birth through 17 years

90746

18 years or older

90747

20 years or older

Influenza

The following places of service and provider types will no longer be reimbursed for procedure codes 90673 and 90682:

Place of Service

Provider Type

Office

Comprehensive Health Center (CHC), Family Planning Clinic

Home

Certified Nurse Midwife, Registered Nurse, Licensed Midwife

Outpatient Hospital

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Physician Group, Certified Nurse Midwife, Registered Nurse, Licensed Midwife, Birthing Center, CHC

Other Locations

Certified Nurse Midwife, Registered Nurse, Licensed Midwife, CHC, Family Planning Clinic

Meningococcal Vaccine

Procedure code 90734 may now be reimbursed to comprehensive care providers (CCP) for services rendered in the office, home, and other settings.

Bacille Calmette-Guerin (BCG) Vaccine

The following places of service and provider types may now be reimbursed for procedure code 90585:

Place of Service

Provider Type

Office

Certified Nurse Midwife, Registered Nurse, Licensed Midwife, Comprehensive Care Program (CCP)

Home

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Physician Group, CCP

Other Locations

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Physician Group, CCP

Procedure code 90585 must be billed with diagnosis code Z201 and will be limited to one service per day, same procedure, any provider.

Hepatitis B Immune Globulin

Procedure codes 90371, J1571, and J1573 must be billed with diagnosis code Z205. Procedure codes J1571 and J1573 will no longer be reimbursed for dentist and dentistry group providers for services rendered in the office setting and for durable medical equipment (DME) medical suppliers for services rendered in the home setting.

Rabies Post-Exposure Prophylaxis

The following places of services and provider types will no longer be reimbursed for procedure codes 90375 and 90376:

Place of Service

Provider Type

Office

Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based

Home

Rural Health Clinic – Freestanding/Independent

Outpatient Hospital

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Clinic/Group Practice, Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based

Other Locations

Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based

The following places of services and provider types will no longer be reimbursed for procedure code 90675:

Place of Service

Provider Type

Office

Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based

Home

Rural Health Clinic – Freestanding/Independent

Outpatient Hospital

Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based

Other Locations

Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based

For more information, call the TMHP Contact Center at 800-925-9126.