CurrentDell Children's Health PlanPolicy N/A

COVID-19 Vaccine and Vaccine Administration Procedure Codes 91318, 91319, 91320, 91321, 91322, and 90480 Are Now Benefits of Medicaid and CHIP

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This policy establishes Medicaid and CHIP benefit coverage, age ranges, provider types, places of service, billing requirements, and claim reprocessing instructions for COVID-19 vaccine codes 91318-91322 and administration code 90480 in Texas.

Policy Summary

PayerDell Children's Health Plan

PolicyCOVID-19 Vaccine and Vaccine Administration Codes

Policy CodePolicy N/A

Change TypeBenefit and billing update

Effective DateSeptember 11, 2023

Next Review DateN/A

Key ActionBill covered COVID-19 vaccine product and administration codes for eligible Medicaid and CHIP members when provider type and place of service meet policy requirements.

SourceLink

POLICY UPDATE CHANGES

Effective for dates of service on or after September 11, 2023, COVID-19 vaccine procedure codes 91318, 91319, 91320, 91321, and 91322 and vaccine administration code 90480 became Medicaid and CHIP benefits.

Health plans must update systems and processes and inform impacted network providers about the code updates.

6 months+Minimum age for administration

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CurrentDell Children's Health PlanPolicy N/A

COVID-19 Vaccine and Vaccine Administration Procedure Codes 91318, 91319, 91320, 91321, 91322, and 90480 Are Now Benefits of Medicaid and CHIP

Customize your policy alerts

Sign up for all dellchildrenshealthplan policy alerts

Know when dellchildrenshealthplan releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerDell Children's Health Plan

PolicyCOVID-19 Vaccine and Vaccine Administration Codes

Policy CodePolicy N/A

Change TypeBenefit and billing update

Effective DateSeptember 11, 2023

Next Review DateN/A

Key ActionBill covered COVID-19 vaccine product and administration codes for eligible Medicaid and CHIP members when provider type and place of service meet policy requirements.

SourceLink

POLICY UPDATE CHANGES

Health plans must update systems and processes and inform impacted network providers about the code updates.

6 months+Minimum age for administration

5Vaccine product codes covered

6Eligible provider/POS combinations

09/11/2023Benefit effective date

20 yearsMaximum Health Steps age

Covered Benefit Requirements

Covered Benefit Criteria

Covered when ALL of the following requirements are met:

ALL of the following

The date of service is on or after September 11, 2023, consistent with the FDA's amended emergency use authorizations for the Pfizer-BioNTech and Moderna COVID-19 vaccines.
ONE covered procedure code and matching member age range
- Procedure code 90480 — COVID-19 vaccine administration for a member 6 months of age or older.
- Procedure code 91318 — COVID-19 vaccine product for a member 6 months through 4 years of age.
- Procedure code 91319 — COVID-19 vaccine product for a member 5 through 11 years of age.
- Procedure code 91320 — COVID-19 vaccine product for a member 12 years of age or older.
- Procedure code 91321 — COVID-19 vaccine product for a member 6 months through 11 years of age.
- Procedure code 91322 — COVID-19 vaccine product for a member 12 years of age or older.
The provider type and place of service are an approved combination
- Office: Physician, physician assistant, nurse practitioner, clinical nurse specialist, pharmacist, certified nurse midwife, registered nurse, licensed midwife, Comprehensive Care Program (CCP) provider, nephrology (hemodialysis or renal dialysis) provider, or pharmacy.
- Home: Physician, physician assistant, nurse practitioner, clinical nurse specialist, CCP provider, or home health agency.
- Outpatient hospital: Hospital, nephrology (hemodialysis or renal dialysis) provider, or renal dialysis facility.
- Other location: Physician, physician assistant, nurse practitioner, clinical nurse specialist, or CCP provider.

Additional Reimbursement Conditions

Additional reimbursement requirements and billing rules apply to administration and vaccine product claims:

ALL applicable conditions

Texas Health Steps providers may be reimbursed for services provided to members 6 months through 20 years of age in office, home, outpatient hospital, and other location settings.
Beginning September 11, 2023, procedure code M0201 (COVID-19 vaccine administration inside a patient's home) may be billed in the home setting with procedure code 90480.
Immunization counseling is included in procedure code 90480; procedure code G0315 may not be billed by the same provider on the same day as procedure code 90480.
Do not separately bill G0315 with 90480 when both services are rendered by the same provider on the same date.
For individuals eligible for the Vaccines for Children (VFC) program, administer vaccines from VFC-provided stock.

Non-Risk Payment Exclusion

The following covered procedure codes are excluded from non-risk payment reimbursement:

Non-risk payment exclusion

Procedure codes 91318, 91319, 91320, 91321, 91322, and 90480 are not covered as non-risk payments under the stated reimbursement criteria.
HHSC will not cover these codes as non-risk payments. The NRP COVID-19 reimbursement criteria had an end date of service of August 31, 2023.

Covered and Excluded Codes

COVID-19 vaccine product codesCPTCovered

91318	COVID-19 vaccine product for individuals 6 months through 4 years of age
91319	COVID-19 vaccine product for individuals 5 through 11 years of age
91320	COVID-19 vaccine product for individuals 12 years of age or older
91321	COVID-19 vaccine product for individuals 6 months through 11 years of age
91322	COVID-19 vaccine product for individuals 12 years of age or older

COVID-19 vaccine administrationCPTCovered

90480

COVID-19 vaccine administration for individuals 6 months of age or older

Home administration add-on billingHCPCS

M0201

COVID-19 vaccine administration inside a patient's home

Same-day exclusion with administrationHCPCSNot Covered

G0315

Immunization counseling; cannot be billed same day by the same provider as 90480

Non-risk payment treatmentmixedNot Covered

91318	COVID-19 vaccine product
91319	COVID-19 vaccine product
91320	COVID-19 vaccine product
91321	COVID-19 vaccine product
91322	COVID-19 vaccine product
90480	COVID-19 vaccine administration

Administration Code 90480

Procedure code90480 — COVID-19 vaccine administration

Applicable age range6 months of age or older

Benefit statusMedicaid and CHIP benefit

Code 91318

Procedure code91318 — COVID-19 vaccine product

Applicable age range6 months through 4 years of age

Billing and Implementation Actions

Billing Rule

Bill Covered Vaccine and Administration Codes

Bill covered COVID-19 vaccine product and administration codes for eligible Medicaid and CHIP members when the provider type and place of service are covered. These benefits apply to dates of service on or after September 11, 2023.

Covered codes: 91318, 91319, 91320, 91321, 91322, and 90480.
Age ranges: 90480—6 months or older; 91318—6 months through 4 years; 91319—5 through 11 years; 91320—12 years or older; 91321—6 months through 11 years; 91322—12 years or older.
Covered settings and provider types: Office—physicians, physician assistants, nurse practitioners, clinical nurse specialists, pharmacists, certified nurse midwives, registered nurses, licensed midwives, Comprehensive Care Program providers, nephrology/renal dialysis providers, and pharmacies; Home—physicians, physician assistants, nurse practitioners, clinical nurse specialists, Comprehensive Care Program providers, and home health agencies; Outpatient hospital—hospitals and nephrology/renal dialysis providers and facilities; Other locations—physicians, physician assistants, nurse practitioners, clinical nurse specialists, and Comprehensive Care Program providers.
Texas Health Steps: Eligible providers may be reimbursed for members ages 6 months through 20 years in office, home, outpatient hospital, and other location settings.

Policy Summary

PayerDell Children's Health Plan

PolicyCOVID-19 Vaccine and Vaccine Administration Codes

Policy CodePolicy N/A

Change TypeBenefit and billing update

Effective DateSeptember 11, 2023

Next Review DateN/A

Key ActionBill covered COVID-19 vaccine product and administration codes for eligible Medicaid and CHIP members when provider type and place of service meet policy requirements.

SourceLink

On This Page

COVID-19 vaccine products administered to individuals 6 months through 18 years of age are processed by TMHP for reimbursement as informational only.

Affected claims with procedure codes 91318, 91319, 91320, 91321, 91322, or 90480 and dates of service on or after September 11, 2023 must be reprocessed by the health plan.

Providers may bill MCOs retroactively for COVID-19 vaccine and vaccine administration procedure codes 91318, 91319, 91320, 91321, 91322, and 90480.

Providers are not required to appeal affected claims unless they are denied for additional reasons after claims reprocessing is complete.

The vaccine must be authorized or approved by the FDA; Texas Medicaid and CHIP do not cover vaccines that are not FDA-authorized or FDA-approved.

Benefit statusMedicaid and CHIP benefit

Code 91319

Procedure code91319 — COVID-19 vaccine product

Applicable age range5 through 11 years of age

Benefit statusMedicaid and CHIP benefit

Codes 91320 and 91322

Procedure codes91320 and 91322 — COVID-19 vaccine products

Applicable age range12 years of age or older

Benefit statusMedicaid and CHIP benefit

Code 91321

Procedure code91321 — COVID-19 vaccine product

Applicable age range6 months through 11 years of age

Benefit statusMedicaid and CHIP benefit

Texas Health Steps

Provider categoryTexas Health Steps providers

Applicable member age range6 months through 20 years of age

Eligible settingsOffice, home, outpatient hospital, and other location settings

Benefit Effective Date

Effective dateDates of service on or after September 11, 2023

Covered servicesCOVID-19 vaccine product codes 91318, 91319, 91320, 91321, and 91322, and administration code 90480

ProgramsMedicaid and CHIP

Billing Rule

Home Administration Billing

For applicable services provided on or after September 11, 2023, bill M0201 for COVID-19 vaccine administration inside a patient's home together with procedure code 90480 in the home setting.

M0201: COVID-19 vaccine administration inside a patient's home.
Use with procedure code 90480 for applicable home services.

Unsupported block type: denial_risk

Billing Rule

Retroactive Billing and Appeals

Providers may bill MCOs retroactively for the covered COVID-19 vaccine and administration codes for dates of service on or after September 11, 2023. Health plans must reprocess affected claims; providers do not need to appeal unless a claim remains denied for additional reasons after reprocessing.

Applicable codes: 91318, 91319, 91320, 91321, 91322, and 90480.
Bill MCOs retroactively when appropriate.
Appeals are unnecessary unless additional denial reasons remain after claim reprocessing.

Billing Rule

Use VFC-Provided Vaccine Stock

Use vaccine stock supplied through the Vaccines for Children (VFC) program when administering vaccines to individuals eligible for VFC.

Vaccines for VFC-eligible individuals must come from VFC-provided stock.
For individuals ages 6 months through 18 years, TMHP processes COVID-19 vaccine products submitted for reimbursement as informational only.

Unsupported block type: denial_risk

Note

Update Systems and Notify Providers

Update systems and processes to reflect the COVID-19 vaccine and administration code updates, and notify impacted providers in the health plan's provider network.

Implement the code updates for dates of service on or after September 11, 2023.
Inform affected network providers of the updated billing and reimbursement requirements.