General Coding
Gardasil/HPV Vaccine/Genital Warts Vaccine
Herpes Zoster Vaccine / Shingles Vaccine / Zostavax
Rotavirus Vaccine
Miscellaneous Drugs
General Coding
Gardasil / HPV Vaccine / Genital Warts Vaccine
The vaccine protects against four HPV types, which together cause 70% of cervical cancers and 90% of genital warts.
CPT Code for vaccine is 90649. It is currently being marketed under the Brand Name Gardasil®.
Things to keep in mind when coding:
- HPV vaccine is a series of three shots over a six-month period.
- The second and third doses should be given two and six months (respectively) after the first dose. The member should complete the series before the age cut off for full reimbursement.
- Authorization is not required.
- Effective for dates of service after September 1, 2006, fully-funded commercial female members aged 9 through 12, but not yet 13, are covered.
- Tentative effective date for Optima Family Care (OFC) / FAMIS is October 1, 2006 (Tentative pending Vaccine for Children availability). The vaccine will cover females aged 9 through 18, but not yet 19 years old.
- For OFC members, the vaccine is covered through the VFC program for OFC members.
- FAMIS members do not receive vaccines through the VFC program.
- Currently, Self-Funded plans are not covering the vaccine.
Herpes Zoster Vaccine / Shingles Vaccine / Zostavax
CPT code is 90736.
Zostavax, is a new vaccine given to reduce the risk of shingles (herpes zoster) in people 60 years of age and older. Shingles is an extremely painful condition is estimated to strike about half of all seniors by the time they reach age 85. Shingles is a disease caused by the varicella-zoster virus, the same virus that causes chickenpox. After an attack of chickenpox, the virus lies dormant in certain nerve tissue. Shingles is characterized by clusters of blisters, which develop on one side of the body and can cause severe pain that may last for weeks, months or years after the virus reappears.
- The vaccine boosts immunity against varicella-zoster virus.
- The vaccine is given as a single injection under the skin, preferably in the upper arm.
Things to keep in mind when coding:
- Effective with dates of service September 1, 2006, vaccine is covered for all commercial and Optima Family Care members 60 year old and older.
- Authorization is not required.
- Self-Funded plans should check plan documents.
Rotavirus Vaccine
Rotavirus is an intestinal virus that infects virtually all children by three years of age. It is the most common cause of diarrhea in children, including hospital-acquired diarrhea, and childcare center outbreaks are common. The disease usually lasts a week or longer and can cause persistent infection in immunocompromised people. Most rotavirus infections are mild, but about 1 in 50 cases develop severe dehydration. Each year in the U.S., rotavirus results in the hospitalization of 50,000 infants younger than two years of age.
CPT code for the vaccine is 90680 (rotavirus vaccine, tetravalent, live for oral use).
Things to keep in mind when coding:
- Effective with September 1, 2006 dates of service, vaccine is covered for all commercial, Optima Family Care and FAMIS members between the age of 0 - 1 year.
- Self-Funded plans are not covering the vaccine
- VACCINE NOTE: If a member receives a non-covered vaccine, both the administration and the vaccine are denied D20 – not a covered benefit-member responsible.
Miscellaneous Drugs
Regardless of the dollar amount for J3490, Optima Health requires for miscellaneous drugs administered in the office (other than oral methods).
- NDC codes for all miscellaneous drug codes.
- NDC codes should appear on the claim form in either block 24k or at the top of the form.
- Electronic submitters should use the 4010 A1 professional version of the 837 and should include the information in loop 2410, with LIN02 = N4 and LIN03 = the NDC number (up to 12 numeric digits).
- Providers who administer chemotherapy mixes should use NDC number 00-000-000-0000 as the primary NDC code, followed by the NDC codes for all drugs used in the mix.
Claims received without a valid NDC code will be denied D95K, Required NDC Number Missing/Invalid-Resubmit–provider responsible.
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View August 2006 Coding Corner