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HIPAA: HIPAA Implementation - Service Codes Conversion

Effective with the September 22, 2003 implementation of the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health Services (DHS) is implementing the use of Current Procedural Terminology – 4th Edition (CPT-4) codes when billing for immunizations. Healthcare Common Procedure Coding System (HCPCS) Level III local codes will no longer be reimbursable by Medi-Cal for dates of service on or after the HIPAA implementation date. Some of the policy changes are highlighted below.

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Deleted HCPCS Codes

The following HCPCS Level III local immunization codes will be deleted effective with the implementation of HIPAA.

X5300 X5332 X6232 X6842 X7106 X7914
X5302 X5334 X6234 X6844 X7438 X7916
X5304 X5336 X6268 X6950 X7439 X7918
X5306 X5338 X6270 X6954 X7440 X7920
X5308 X5340 X6272 X6956 X7441 X7922
X5310 X5342 X6276 X6960 X7472 X7924
X5312 X5344 X6279 X6990 X7474 X7926
X5314 X5346 X6281 X7024 X7476 X7930
X5316 X5676 X6314 X7088 X7900 X7932
X5318 X5730 X6350 X7090 X7902 X7934
X5320 X5938 X6538 X7092 X7904 X7936
X5321 X6098 X6542 X7094 X7906 X7938
X5322 X6100 X6768 X7096 X7908 X7940
X5324 X6102 X6772 X7098 X7910 X7942
X5326 X6218 X6774 X7100 X7912  
X5330 X6230 X6840 X7102 X7913  

Note: All HCPCS codes listed above remain payable only with a date of service prior to the September 22, 2003 implementation date.

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CPT-4 Codes

Immunization services rendered on or after September 22, 2003 must be billed using the appropriate CPT-4 code from the following list:

90281 90585 90658 90701 90717 90743
90283 90586 90659 90702 90718 90744
90371 90632 90665 90703 90719 90746
90378 90633 90669 90704 90720 90747
90379 90634 90675 90705 90721 90748
90384 90636 90676 90706 90723 90749
90385 90645 90690 90707 90725  
90386 90646 90691 90708 90727  
90389 90647 90692 90712 90732  
90399 90648 90693 90713 90733  
90471 90657 90700 90716 90740  

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Vaccines For Children (VFC) Program

Vaccine For Children (VFC) Program providers are required to use CPT-4 codes and the -SL modifier. The -SK modifier must also be used with VFC vaccine codes when appropriate.

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CPT-4 Codes with Modifier -SL (State-Supplied Vaccine)

Providers must use a VFC-provided vaccine when available and use modifier -SL with the CPT-4 code to bill for these immunizations. VFC providers who bill modifier -SL with the CPT-4 codes will be reimbursed only the Medi-Cal VFC program administration fee. The following codes must be billed with an -SL modifier for recipients 18 years of age and younger when using VFC-provided vaccines:

90632 90646 90659 90703 90713 90723
90633 90647 90669 90705 90716 90743
90634 90648 90700 90706 90718 90744
90636 90657 90701 90707 90720 90746
90645 90658 90702 90712 90721 90748

Note: Medi-Cal providers who are not VFC providers cannot use modifier -SL, since this service is available only for VFC providers.

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CPT-4 Codes with Modifier -SK (High Risk)

Providers are required to bill modifier -SK with the CPT-4 codes listed below if the recipient is at high risk for the disease or condition for which the immune globulin/vaccine/toxoid is given. Providers are required to document in the recipient's medical record the medical reason why the recipient is "high risk" for the disease or condition for which the injection was administered. Providers are no longer required to submit the reason for high risk on the claim, but must do so on the medical record. The medical justification must meet Medi-Cal program policy for the immunization billed.

90632 90657 90675 90692 90725
90633 90658 90676 90693 90727
90634 90659 90690 90704 90732
90636 90665 90691 90717 90733

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CPT-4 Codes with Modifier -SL and -SK

The following CPT-4 codes require both the -SL and -SK modifiers. These codes must be billed with both modifiers unless the VFC vaccine is not available.

90632 90634 90657 90659
90633 90636 90658  

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Vaccine Availability

Providers unable to obtain VFC program vaccines in time to immunize VFC eligible recipients can bill the appropriate CPT-4 code for recipients younger than 19 years of age without the -SL modifier. Providers who bill any of the table listed codes for recipients younger than 19 years of age without modifier -SL are required to document justification why VFC vaccine was not used in the Reserved For Local Use field (Box 19) of the claim or on a separate attachment. A provider's non-enrollment in the VFC program is not considered justification and such claims will be denied.

VFC providers who bill the CPT-4 code but do not use the modifier -SL when required must document all of the following:

  • The recipient is 18 years of age or younger,
  • The provider has not used modifier -SL, and
  • At least one of the following justifications is on the claim: a vaccine shortage, disease epidemic, VFC vaccine delivery problems or the recipient does not meet special circumstances required by the VFC program for the vaccine being billed.

Claims without such documentation will be denied and/or subject to audit.

Note: Providers are reminded that use of any vaccine or immunization solely for the purpose of travel or requirement of employment is not a Medi-Cal benefit.

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Documentation for CPT-4 Codes 90399, 90749 and 90471

Effective for dates of service on or after the September 22, 2003 HIPAA implementation, reimbursement for CPT-4 code 90399 (unlisted immune globulin) and 90749 (unlisted vaccine/toxoid) require the name of the vaccine used, an invoice of the actual cost of the vaccine as well as medical justification in the Reserved For Local Use field (Box 19) of the claim. Claims without such documentation will be denied. These codes may only be used when no CPT-4 code currently exists that could otherwise be used to bill for the immunization.

Claims billed for CPT-4 code 90471 (Immunization administration; one vaccine) require the name of the vaccine and medical justification in the Reserved For Local Use field (Box 19) of the claim. Claims without such documentation will be denied. Providers cannot claim reimbursement for CPT-4 code 90471 for any vaccine that has an existing CPT-4 code since the Medi-Cal program already includes the administration fee in the reimbursement for the other CPT-4 immunization code billed.

Note:

Code 90471 is billable only for administration of non-VFC vaccines that are furnished free of charge to the provider. CPT-4 code 90741 must not be billed for free vaccine supplied by the VFC program. Providers may not bill CPT-4 code 90741 for an additional administration fee when billing any other immunization code for the same immunization. CPT-4 code 90741 pays the usual non-VFC Medi-Cal program injection fee.

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Documentation for CPT-4 Codes 90675 and 90676

Effective for dates of service on or after the September 22, 2003 HIPAA implementation, reimbursement for CPT-4 codes 90675 and 90676 (rabies vaccine) requires an invoice indicating the cost of the vaccine.

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CPT-4 Code Unit Values

Some CPT codes are assigned specific unit values for Medi-Cal reimbursement purposes. Providers should note the unit values for the following CPT-4 codes that become effective on September 22, 2003:

CPT-4 Code Unit Value CPT-4 Code Unit Value
90281 1 ml 90740 40 mcg
90283 1 gram 90743 10 mcg
90371 1 ml 90744 10 mcg
90378 50 mg 90746 10 mcg
90379 250 mg 90747 40 mcg
90386 600 units    

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ORTHOTICS AND PROSTHETICS
Procedure Codes

Effective for dates of service on or after September 22, 2003, all California-only “local” Orthotics and Prosthetics HCPCS codes (X8100 – X9050) will be terminated. National-level HCPCS codes are available to bill for these services. In addition, orthotic and prosthetic consultation (code X9030) and mileage (code X9032) will no longer be Medi-Cal benefits.

Modifiers

Effective for dates of service on or after September 22, 2003, California-only modifiers -Y2, -Y3, -Y7 and -Y8 will no longer be available for use with orthotic and prosthetic appliances. These modifiers, however, will remain available for Durable Medical Equipment (DME) items and hearing aids until further notice. Modifiers -Y4 and -Y9 will continue to be available to bill for undeliverable custom-made items. National-level modifiers -LT (left side), -RT (right side) and -RP (replacement and repair) will be available for Medi-Cal billing.

Manual pages reflecting these changes will be released in a future Medi-Cal Update.

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