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Minnesota Department of Human Services Provider Manual
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Immunizations & Vaccinations

Revised: 01-12-2018

Overview

This section includes Minnesota Health Care Programs (MHCP) vaccination coverage and billing policy for children and adults. MHCP coordinates with the Minnesota Department of Health’s (MDH) Minnesota Vaccine for Children (MnVFC) program to provide pediatric vaccines at no cost for providers enrolled in MDH MnVFC program. The MDH MnVFC program is for MHCP members’ birth through 18 years old. For more information about free vaccine availability from MDH through MnVFC program, please visit: http://www.health.state.mn.us/divs/idepc/immunize/index.html.

Flu vaccines and other recommended vaccinations for adults enrolled in MHCP are covered. Providers must use their private stock to bill MHCP for all covered adult vaccines and for administering the vaccine.

Eligible Providers

The following MHCP-enrolled health care providers may bill for vaccines and toxoids and administering vaccines and toxoids:

  • • Certified family nurse practitioners
  • • Certified pediatric nurse practitioners
  • • Certified nurse-midwives
  • • Child and Teen Checkups providers
  • • Clinics
  • • Convenience clinics
  • • Home health agencies
  • • Outpatient and inpatient hospitals
  • • Pharmacies
  • • Physicians
  • • Public health clinics
  • • Public health nursing clinic providers
  • • Dental providers
  • Minnesota Statutes (256B.0625, subd. 39) requires all MHCP enrolled providers who administer pediatric vaccines to enroll in the MDH MnVFC program.

    Minnesota Statutes (151.01, subd. 27) allows pharmacies to bill for flu vaccines administered by pharmacists to children and all other vaccines to adults. Effective July 1, 2015, pharmacists can bill for flu vaccines administered to children ages six and older and all other vaccines to people who are aged 13 or older under standing orders from a licensed physician or by written protocol with a physician provided that the pharmacist meets the following:

  • • Is trained in a program approved by the American Council of Pharmaceutical Education for the administration of vaccinations or graduated from a college of pharmacy in 2001 or after
  • • Reports the administration of the vaccinations to the Minnesota Immunization Information Connection (MIIC),
  • • Uses the MIIC to assess the immunization status of a person before administering vaccines, except when administering influenza vaccines to a person age nine or older
  • Minnesota Statutes (150A.055) allows dentists who meet all of the following to administer influenza vaccines to patients aged 19 and older:

  • • Are trained in or have successfully completed a program approved by the Minnesota Board of Dentistry specifically for the administration of immunizations and must submit attestation on the Immunization Delivery for Dentists Applicant Assurance Statement (DHS-7121) (PDF)
  • • Have immediate access to emergency response equipment, including but not limited to oxygen administration equipment, epinephrine, and other allergic reaction response equipment
  • • Reports the administration of the immunization to Minnesota Immunization Information Connection or the patient’s primary physician or clinic
  • Non-Eligible Recipients

    Recipients enrolled in the following MHCP programs are not eligible for MHCP vaccination services:

    AC
    HH
    EH
    FP

    Alternative Care Program
    HIV/AIDS
    Emergency Medical Assistance
    MN Family Planning Program

    Covered Services

    MHCP covers the following services:

  • • Vaccines (See Quick Reference Guide at the end of this section)
  • • Toxoids (See Quick Reference Guide at the end of this section)
  • • Administering vaccines and toxoids, including those available through the MDH Vaccine program
  • • Office visits associated with administering vaccinations when the appointment is not solely to administer vaccinations
  • Noncovered Services

    MHCP does not cover the following services:

  • • Reimbursement for vaccines available from the MDH MnVFC program that are not obtained and used
  • • Reimbursement for vaccines is not available under IEP services
  • Claim lines deny when billing the following:

  • • A vaccine code is billed without a vaccine administration code.
  • • A vaccine administration code is billed without a vaccine code.
  • Administering Vaccines – Billing and Payments

    Refer to the following billing and payment information:

  • • Bill office visits associated with administering vaccinations when the visit is not solely to administer vaccines
  • • Effective for service dates starting January 1, 2018, the base rate for vaccine administration is the lower of the provider’s submitted charge or the resource based relative value scale (RBRVS) rate. The paid amount is not to exceed the Centers for Medicare and Medicaid Services (CMS) Minnesota maximum vaccine administration fee
  • Vaccine Administration Codes

    90460* (first or only component of each vaccine/ toxoid)

    90461 (each additional vaccine/ toxoid component)

    90471 (1 single or combination vaccine/toxoid)

    90472 (each additional vaccine, single or combination vaccine/toxoid)

    90473 (intranasal or oral administration, single or combination vaccine/toxoid)

    90474 (each additional vaccine, single or combination vaccine/toxoid)

    G0008 flu (initial)

    G0009 PPV (initial)

    G0010 Hep B (initial)

    *Code 90460 (with counseling) is considered the initial administration code when billed with other non-counseling vaccine administration codes.

    Please note: The vaccine administration fee cap rates were established on a per-vaccine basis, not a per-antigen or per-component basis. Under current interpretation of CMS policy, the administration fee will continue to be based on a per-vaccine basis and not on a per-antigen or per-component basis. Providers are encouraged to use CPT code 90460 for the administration of a vaccine under the MnVFC program. If code 90461 is used for a vaccine with multiple antigens or components, it would be given a $0 value.

    Vaccines obtained from the MDH MnVFC Program

    When billing MHCP for the administration fee for vaccines obtained from MDH, bill using the procedure code that represents the immunization administered and add a SL modifier (state supplied vaccine) to receive MHCP payment. For example, the CPT or procedure code for MMR vaccine is 90707. To receive payment from MHCP for the administration fee for this vaccine, you should include 90707-SL on the MHCP claim line. MHCP will only reimburse for the administration fee, not the cost of the vaccine.

    Refer to the following when billing for MDH MnVFC vaccines:

  • • Use the 837P or 837I MN–ITS transaction
  • • Enter the appropriate vaccine code with the SL modifier and a $0.00 charge
  • • Enter the appropriate vaccine administration code on the same claim
  • • Enter the administration charge for administering the vaccine
  • MHCP does not reimburse for vaccines obtained at no cost from MDH MnVFC program.

    Billings for Vaccines NOT Obtained From MnVFC Program and for Adult Vaccines

    MHCP reimburses for children’s vaccines only when the vaccines are not available through the MDH MnVFC program.

    Bill for children’s vaccines that are not available from MnVFC program and adult vaccines according to the following:

  • • Use the 837P or 837I MN–ITS transaction
  • • Enter the appropriate vaccine code and vaccine administration code on the same claim
  • • Do not enter modifier SL with the vaccine code
  • • Enter the usual and customary vaccine charge and the administration charge for administering the vaccine
  • Payments are based on the lowest of:

  • • Submitted charge
  • • Medicare’s average sale price (ASP) plus six percent
  • • The wholesale acquisition cost if Medicare has not established an ASP
  • Seasonal Influenza Vaccines

    Availability of annual seasonal flu vaccine and distribution timing vary. Contact MDH for information about flu season and availability and distribution of flu vaccine or refer to www.health.state.mn.us/divs/idepc/immunize/hcp/index.html.

    Providers must obtain pediatric flu vaccines from the MDH MnVFC Vaccine program when available.

    Code

    Ages

    90655

    6–35 months

    90656

    3 years and older

    90657

    6–35 months

    90658

    3 years and older

    90672

    2 years to 18 years

    90674

    4 years and older

    90685

    6–35 months

    90686

    6 months and older

    90687

    6–35 months

    90688

    6 months and older

    Q2035

    3 years and older

    Q2037

    3 years and older


    Seasonal Flu Vaccines for Ages 19 and Older

    Code

    Ages

    90630

    19 through 64 years

    90653

    65 years and older

    90654

    19 through 64

    90656

    19 years and older

    90658

    19 years and older

    90661

    19 years and older

    90662

    65 years and older

    90672

    19 through 49 years

    90673

    19 through 49 years

    90682

    19 years and older

    90686

    19 years and older

    90688

    19 years and older

    Q2033 (Medicare)

    19 years through 49

    Q2034 (Medicare)

    19 years and older

    Q2035 (Medicare)

    19 years and older

    Q2036 (Medicare)

    19 years and older

    Q2037 (Medicare)

    19 years and & older

    Q2038 (Medicare)

    19 years and older

    MHCP Vaccines and Toxoids Quick Reference

    Refer to the Centers for Disease Control and Prevention VFC Vaccine Resolutions for more information.

    Code

    Description

    Age Range

    Available from MDH MnVFC Program?

    90620

    Meningococcal – Bexsero

    10 years through 25 years

    Yes

    90621

    Meningococcal –Trumenba

    10 years through 25 years

    Yes

    90630

    Influenza

    19 through 64 years

    No

    90632

    Hepatitis A

    19 years and older

    No

    90633

    Hepatitis A

    18 years and younger

    Yes

    90636

    HepA-HepB

    19 years & older

    No

    90644

    Hib-Mency

    6 -18 months

    Yes

    90647

    Hib,PRP-OMP conjugate

    2 months – 5 years

    Yes

    90648

    Hib, PRP-T conjugate

    2 months – 5 years

    Yes

    90649

    HPV

    Females and males 9 through 28 years

    Yes

    90650

    HPV

    Females 9 through 28 years

    Yes

    90651

    HPV

    Females and males 9 through 28 years

    Yes

    90653

    Influenza

    65 years and older

    No

    90654

    Influenza

    19 through 64 years

    No

    90655

    Influenza

    6–35 months

    Yes

    90656

    Influenza

    3 years and older

    Yes

    90657

    Influenza

    6–35 months

    Yes

    90658

    Influenza (FluLaval IIV3)

    3 years and older

    Yes

    90661

    Influenza (Flucelvax (ccllv3)

    19 years and older

    No

    90662

    Influenza

    65 years and older

    No

    Q2033

    Influenza

    19 years through 49 years

    No

    Q2034

    Influenza

    19 years and older

    No

    Q2035

    Influenza (Afluria)

    3 years and older

    No

    Q2036

    Influenza (Flulaval)

    19 years and older

    No

    Q2037

    Influenza (Fluvirin)

    3 years and older

    No

    Q2038

    Influenza (Fluzone)

    3 years and older

    Yes

    Q2039

    Influenza (NOS flu)

    3 years and older

    Yes

    90669

    Pneumococcal

    2–59 months

    Yes

    90670

    PCV 13/Prevnar 13

    6 weeks and & older

    Yes

    90672

    Influenza (FluMist)

    2 years though 49 years

    Yes

    90673

    Influenza (Flublok)

    19 years through 49 years

    No

    90674

    Influenza (Flucelvax (ccIIV4)

    4 years and older

    Yes

    90680

    Rotavirus

    6 weeks–8 months

    Yes

    90681

    Rotavirus

    6 weeks–8 months

    Yes

    90682

    Influenza (Quadrivalent (RIV4),

    19 years and older

    No

    90685

    Influenza (Fluzone)

    6–35 months

    Yes

    90686

    Influenza (Fluzone)

    6 months and older

    Yes

    90687

    Influenza (Fluzone)

    6–35 months

    Yes

    90688

    Influenza (Fluzone)

    6 months and older

    Yes

    90696

    DTap-IPV

    4 through 6 years

    Yes

    90698

    DTaP-HIB-IPV

    4 years and younger

    Yes

    90700

    DTaP

    7 years and younger

    Yes

    90702

    DT

    7 years and younger

    Yes

    90707

    MMR

    12 months and older

    Yes

    90710

    MMRV

    12 years and younger

    Yes

    90713

    IPV

    6 weeks and older

    Yes

    90714

    Td

    7 years and older

    Yes

    90715

    Tdap (Adacel)

    11 – 64 years

    Yes

    90715

    Tdap (Boostrix)

    10 years and older

    Yes

    90716

    Varicella virus

    12 months and & older

    Yes

    90723

    DtaPHepB-IPV

    6 years and younger

    Yes

    90732

    PPSV23 (Pneumococcal polysaccharide)

    2 years and older

    Yes

    90734

    Meningococcal

    2 months and older

    Yes

    90736

    Zoster

    50 and older

    No

    90740

    Hepatitis B

    2 months and older

    Yes

    90744

    Hepatitis B

    18 years and younger

    Yes

    90746

    Hepatitis B

    19 years and older

    No

    90747

    Hepatitis B

    2 months and older

    Yes

    90748

    HepB-Hib

    2 months and older

    Yes

    90750

    Zoster (shingles) hzv

    50 years and older

    No

    MHCP Quick Reference for Vaccine and Toxoid Administration Codes

    Enter the appropriate administration code with each single or combination vaccine or toxoid.

    Code

    Use to report administering:

    Administration Route

    MHCP Limitations

    90460

    Single or 1st vaccine/toxoid component of combination vaccine

    Any

  • • 18 years and younger
  • • Physician or other health care professional counseling
  • • Report multiple units on same line
  • • First/only vaccine/toxoid component
  • • Use with 90461, 90472 or 90474
  • 90461

    Each additional component of combination vaccine

    Any

  • • Use only with 90460
  • • Report multiple units on same line
  • • Use to report each additional vaccine/toxoid component
  • 90471

    1 vaccine (single or combination)

    Percutaneous
    Intradermal
    Subcutaneous
    Intramuscular

    Do not use with 90473

    90472

    Each additional vaccine

    Percutaneous
    Intradermal
    Subcutaneous
    Intramuscular

    Use with 90460, 90471 or 90473; list separately (not on same line)

    90473

    1 vaccine (single or combination)

    Oral
    Intranasal

    Do not use with 90471

    90474

    Each additional vaccine (single or combination)

    Oral
    Intranasal

    Use with 90460, 90471 or 90473; list separately (not on same line)

    G0008

    Single or 1st vaccine/toxoid component of combination vaccine

    Any

  • • Billed with vaccine codes: 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90672, 90673,90674, 90682, 90685,90686, 90687, 90688,Q2033, Q2034, Q2035, Q2036, Q2037, Q2038, Q2039
  • • Use with 90472 or 90474 list separately (not on same line)
  • G0009

    Single or 1st vaccine/toxoid component of combination vaccine

    Any

  • • Billed with vaccine codes: 90669, 90670, 90732
  • • Use with 90472 or 90474 list separately (not on same line)
  • G0010

    Single or 1st vaccine/toxoid component of combination vaccine

    Any

  • • Billed with vaccine codes: 90740, 90744, 90746, 90747
  • • Use with 90472 or 90474 list separately (not on same line)
  • Legal References

    Minnesota Statutes 256B.0625, subd.39 Covered Services–Childhood Immunizations
    Minnesota Statutes 151.01, subd.27
    allows pharmacies to administer flu vaccines to children six years and older and all other vaccines to people who are 13 years old and older
    Minnesota Statutes 150A.055
    allows dentists to administer flu vaccines to adults 19 years of age and older

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