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The Health Care Authority is sending this Provider Alert to further clarify a previous Provider Alert sent on May 31, 2024, regarding the Vaccines for Children (VFC) program and billing changes.
Effective for dates of service on and after July 1, 2024, HCA began allowing providers to bill for the administration of VFC vaccines. Under the previous policy, providers were able to bill only for the vaccine code with modifier SL. With this policy update, providers may bill for the vaccine administration code and the vaccine code with modifier SL.
This change was made to ensure uniformity and consistency across billing practices for VFC and non-VFC vaccines. This change is budget neutral to providers, ensuring that providers are reimbursed at approximately the same level as under the previous billing policy.
Billing
- For most VFC vaccines, bill the appropriate administration code (CPT® code 90471-90474) and bill for the vaccine procedure code with modifier SL.
- For RSV (CPT® codes 90380 and 90381), bill for the appropriate administration code (CPT® code 96380 or 96381) and bill for the vaccine procedure code with modifier SL.
- For COVID-19 vaccines, bill for the administration code (CPT® code 90480) and bill the vaccine procedure code with modifier SL.
- Administration CPT® codes 90460-90461 are not allowed with VFC vaccines.
Example
(reimbursement rates provided in this example are effective July 1, 2024, and may change in the future)
| 90471 |
First vaccine injection administration |
$21.20 |
| 90700-SL |
DtaP vaccine |
$2.62 |
| 90472 |
2nd vaccine injection administration |
$14.99 |
| 90657–SL |
Fluzone Trivalent |
$2.62 |
In this scenario, if a patient needed a third vaccine, that vaccine code would also be billed with the SL modifier, as well as another 90472 to indicate a third vaccine administration service.
Billing Guide and Fee Schedule
HCA revised the EPSDT Well-Child Program Billing Guide, July 1, 2024, to reflect this change. Also, HCA revised the Enhanced Pediatric, Physician-Related/Professional Services, and Professional Administered Drug Fee Schedules. See HCA’s Provider billing guides and fee schedules.
Current Procedural Terminology (CPT) copyright 2023 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
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