Currentblue cross blue shield - arizonaPolicy N/A

VFC vaccine coding and reimbursement

Guidance on coding and reimbursement for Vaccines for Children (VFC) program immunizations for AHCCCS members; affects providers billing vaccine and vaccine administration claims in Arizona.

Policy Summary

Payerblue cross blue shield - arizona

PolicyVFC vaccine coding and reimbursement

Policy CodePolicy N/A

Change TypeOperational / Clarification

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionReport VFC vaccine administration with CPT 90460 and add the SL modifier; do not submit claims with 90461.

SourceLink

POLICY UPDATE CHANGES

CPT code 90461 is closed and any claim with 90461 will be denied.

When VFC stock vaccine is administered, both the vaccine code and the administration code must include the SL modifier.

Administration fees are per vaccine administration (per injection), not per antigen; multiple injections are paid separately when reported with CPT 90460 and SL.

Only CPT code 90460 with SL modifier is billable for VFC immunization administration; claims must include toxoid, rendering provider, and use correct form fields.

1administration code allowed for VFC (90460)

1administration code removed (90461)

per injectionadministration fee payment basis

SLmodifier required

AZstate reporting requirement

VFC Billing and Payment Criteria

VFC billing and payment criteria

Billing and payment rules for VFC vaccines administered to members under 18

When VFC stock is used, providers must report both the vaccine CPT/HCPCS code and the administration CPT code with the SL modifier.

Only CPT 90460 with SL is billable for VFC immunization administration; CPT 90461 is closed effective 10/1/24 and any claim with 90461 will be denied regardless of modifier.

When more than one vaccine is administered by separate injections to a member 18 years of age or younger with counseling, report each injection with CPT 90460 and the SL modifier; payment will be made separately for each injection.

Administration fees are per vaccine administration (per injection) and not per antigen; do not split combined-antigen vaccines into separate single-antigen injections to obtain additional administration payments.

Policy Summary

Payerblue cross blue shield - arizona

PolicyVFC vaccine coding and reimbursement

Policy CodePolicy N/A

Change TypeOperational / Clarification

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionReport VFC vaccine administration with CPT 90460 and add the SL modifier; do not submit claims with 90461.

SourceLink

On This Page

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Administration Codes and Payment Basis

VFC administration codesCPTCovered

90460	Immunization administration with counseling, per injection (billable for VFC with SL modifier)
90461	Immunization administration (closed for VFC; claims with this code will be denied)

VFC administration codes - status notemixed

90460	Only code billable for VFC immunization administration when reported with SL modifier
90461	Closed effective 10/1/24 — any claim with 90461 will be denied

Administration per injection

Payment basisAdministration fees are paid per separate injection; each separate administration reported with CPT 90460 + SL is payable.

Combined-antigen ruleIf multiple antigens are delivered in a single injection, additional administration payment will not be made for the included toxoids (single administration fee applies).

Prohibition on splittingDo not separate combined-antigen vaccines into multiple single-antigen injections to obtain extra administration payments; this is not allowed under ACA section 1903(i)(15).

Age limitationReporting multiple injections with 90460 + SL applies when vaccines are administered to members 18 years of age or younger.

Required Billing Actions and Denial Risks

Billing Rule

Use 90460 + SL for VFC administration; 90461 is closed

Report vaccine administration for VFC vaccines using CPT code 90460 and append the SL modifier to the administration claim; do not submit CPT 90461 because it is closed and any claim containing 90461 will be denied effective 10/1/24.

Apply SL modifier to both the vaccine code and the administration code when VFC stock is used.
Claims with 90461 will be denied regardless of modifier; only 90460 with SL is billable for VFC administration.
When filing CMS-1500 (Box 24/19/17) or UB-50/UB-04, include 90460 with SL, the toxoid administered, and the rendering provider.
Do not add SL for vaccines administered to members over 18 or for non‑VFC pediatric vaccines.

OpenPayer

VFC vaccine coding and reimbursement

VFC Billing and Payment Criteria

Administration Codes and Payment Basis

Required Billing Actions and Denial Risks

Modifier and Term Definitions