Effective with the September 22, 2003 implementation of the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health Care 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.

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.

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

Vaccines For Children (VFC) Program

Vaccines 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 as described later in this document.

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 because this service is available only for VFC providers.

Partial Billing Example Using the -SL Modifier

CPT-4 Codes 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/vaccines/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

Partial Billing Example Using -SK Modifier

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

90633

90634

90636

90657

90658

90659

Partial Billing Example Using -SL/-SK Modifiers

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 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.

Required Criteria/Documentation for CPT-4 Codes

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) area 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) area 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 90471 must not be billed for free vaccine supplied by the VFC program. Providers may not bill CPT-4 code 90471 for an additional administration fee when billing any other immunization code for the same immunization. CPT-4 code 90471 pays the usual non-VFC Medi-Cal program injection fee.

90665 Lyme Disease

• Individuals who are 15-70 years of age
• Individuals who are not pregnant, immunocompromised or do not have chronic arthritis; and
• Individuals who live or work in conditions that involve repeated and prolonged physical contact with natural vegetation in tick habitat; and
• Individuals who have a significant risk of exposure to tick bites (and therefore secondary infection with Borrelia burgdorferi) such as wooded areas near the costal range north of San Francisco to the Oregon border, the Sierra foothills, San Francisco Bay and Santa Cruz County.

90675 and 90676 Rabies Vaccines

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

Medical justification for the rabies vaccine is required for individuals who live or work in conditions that involve repeated and prolonged physical exposure to animals and animal bites that may transmit rabies. Examples of such animals are bats, dogs, wolves, skunks, raccoons, foxes, coyotes and bobcats. Medical justification is also required for recipients who have been bitten by an animal that can carry the rabies organism.

Below are the conditions under which the following vaccine procedures codes can be billed:

90690, 90691, 90692 and 90693 Typhoid Vaccines

• Recipients who work in microbiology laboratories
• Recipients who live with or have intimate contact with a typhoid carrier that has been documented
• Individuals exposed to contaminated food or water who reside in an area with a recent case of documented typhoid
• Foreign travel is not an accepted justification for the Medi-Cal program unless the individual was in a household with a known carrier or had intimate contact with a known carrier, contaminated water or food during the travel

90717 Yellow Fever Vaccine

• Recipients who live with a person documented to have yellow fever
• Individuals who reside in or recently visited in an area with a recent case of documented yellow fever
• Foreign travel is not an accepted justification for the Medi-Cal program unless the individual is returning from an area where yellow fever victims were recently present

90725 Cholera Vaccine

• Recipients who live with or have intimate contact with a person documented to have cholera
• Individuals who recently visited in an area with a resent case of documented cholera
• Individuals exposed to contaminated food or water who reside in an area with a recent case of documented cholera
• Foreign travel is not an accepted justification for the Medi-Cal program unless the individual was in household contact with a known carrier or exposed to contaminated water or food during the travel in an area with known cases of cholera

90727 Plague Vaccine

• Recipients who live in an area with or have had recent contact (such as camping in an area) with rodents (rats, mice, squirrels, chipmunks, etc.) documented to harbor fleas carrying the plague organism (Pasteurella pestis)
• Individuals who have recently visited an area with a recent case of documented plague

90733 Meningococcal Vaccine

• Recipients who will reside in a college dormitory
• Recipients who have deficiencies in Compliment factors C3 and C5-C9
• Recipients with functional (such as Sickle Cell disease) or anatomic asplenia
• Recipients who reside with (home, residence hall or dormitory) or have had intimate contact with a known case of meningococcal disease
• Individuals who work in clinical laboratories with exposure to meningococcal organisms
• Foreign travel is not an accepted justification for the Medi-Cal program unless the individual was in household contact with a known carrier

Note: Medical justification not found in the above criteria should be sent for medical review as there may be additional acceptable circumstances that would allow payment of the claim.

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

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