Vaccines for Children Policy and Coding Update

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The South Carolina Department of Health and Human Services (SCDHHS) is revising agency policies related to the administration of vaccines obtained through the Vaccines for Children (VFC) program to Healthy Connections Medicaid-enrolled children. The guidance and changes to vaccine administration and counseling policy included in this bulletin replace the existing SCDHHS guidance on this topic.

SCDHHS will continue to reimburse providers for administering age-appropriate vaccinations. For Healthy Connections Medicaid-enrolled children, providers must continue to obtain vaccine doses through the VFC program.

Additional Administrations and Clarification Regarding Current Procedural Terminology (CPT) Codes 90460 and 90461
SCDHHS will reimburse providers for CPT codes 90460 and 90461 as described below for dates of service on or after Sept. 1, 2020.

Code 90460
SCDHHS will reimburse providers for CPT code 90460 when administering a vaccination with counseling by a physician or other qualified health care professional to a Healthy Connections Medicaid member 18 years of age or younger when it includes the first vaccine/toxoid component. The vaccine may be administered through any route.

To allow for reimbursement for the administration of all vaccines included on the Centers for Disease Control and Prevention (CDC) immunization schedule, including catching up with missed vaccines, SCDHHS will allow for up to nine administrations per visit. Providers should use their professional judgement when determining the appropriate vaccines administered during each visit.

Code 90461
SCDHHS will reimburse providers for CPT code 90461 as an add-on code to 90460. This means that the provider can use 90461 in addition to 90460 for the associated counseling if more than one component is contained within a single vaccine administered. SCDHHS has expanded this benefit to allow up to eight components to be billed per visit.

Providers should refer to the SCDHHS fee schedule for pricing information. Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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