New York State Medicaid Update - September 2022 Volume 38 - Number 10

In this issue …

Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.


Update to New York State Medicaid Fee-for-Service Program Pharmacists as Immunizers Fact Sheet

Updates are highlighted in yellow

In accordance with New York State (NYS) Education law, pharmacists certified to administer immunizations are authorized to administer to patients 18 years of age and older, as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control and Prevention (CDC). The following vaccines can now be obtained by NYS Medicaid members, 18 years of age and older:

  • Coronavirus Disease 2019 (COVID-19)
  • Hepatitis A
  • Hepatitis B
  • Herpes zoster (shingles)
  • Human papillomavirus
  • Influenza (two years of age and older)
  • Measles, mumps, and rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, diphtheria, and pertussis
  • Varicella

Providers can refer to the NYS Department of Health New York State Medicaid Coverage Policy and Billing Guidance for the Administration of COVID-19 Vaccines, for more information.

The following conditions apply:

  • Only NYS Medicaid-enrolled pharmacies will receive reimbursement for immunization services. Services must be provided and documented in accordance with state laws and regulations, including the reporting of all immunizations administered to persons less than 19 years of age to either the State Department of Health (DOH), using the New York State Immunization Information System (NYSIIS), or to the New York Citywide Immunization Registry (CIR). Additional information can be found on the State Education Department (SED) "Administration of Immunizations" web page.
  • Pharmacies will only be able to bill for NYS Medicaid non-dual-eligible enrollees. Dual-eligible enrollees will continue to access immunization services through Medicare.
  • Medicaid Managed Care (MMC) enrollees will continue to access immunization services through their health plans.
  • Reimbursement for these vaccines may be based on a patient-specific order or non-patient specific order. These orders must be kept on file at the pharmacy. For patient-specific orders, the ordering prescriber National Provider Identification (NPI) number is required on the claim for the claim to be paid.
  • Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) for individuals younger than 19 years of age are provided to NYS Medicaid members, both fee-for-service (FFS) and MMC, free of charge by the Vaccines for Children (VFC) program.
    • Pharmacies wishing to administer VFC-available vaccines to NYS Medicaid members younger than 19 years of age may enroll in the VFC program. Please note: The VFC program is currently enrolling pharmacies to receive the influenza vaccine only. Pharmacies immunizing patients 18 years of age with pneumococcal, meningococcal, tetanus, diphtheria and pertussis, hepatitis A, hepatitis B, human papillomavirus, measles, mumps, and rubella, and varicella vaccines may not bill NYS Medicaid for the costs of these vaccines. Patients younger than 19 years of age, and enrolled in NYS Medicaid, are VFC-eligible and may receive these vaccines through a VFC health care practice or clinic. Pharmacies that bill NYS Medicaid for the cost of vaccines that are available through the VFC program are subject to recovery of payment.
    • Pharmacies that are not enrolled in the VFC program may choose to provide vaccines for members younger than 19 years of age, at no charge to the member or NYS Medicaid program, and will be reimbursed an administration fee of $17.85 by NYS Medicaid.
    • Additional information on the VFC program, based on location, can be found at the following websites:

Billing Instructions for FFS

Consistent with Medicaid immunization policy, pharmacies will bill the administration fee and, when applicable, acquisition cost of the vaccine using the appropriate procedure codes. Procedure codes can be found on the Pharmacy Fee Schedule.

Please note: National Drug Codes (NDCs) are not to be used for billing the vaccine product to Medicaid FFS. Reimbursement for the cost of the vaccine for individuals 19 years of age and older will be made at no more than the actual acquisition cost to the pharmacy. No dispensing fee or enrollee co-payment applies. Pharmacies will bill with a quantity of "1" and a day supply of "1."

Vaccine claims submitted via the National Council for Prescription Drug Programs (NCPDP) D.0 format

NCPDP D.0. Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter value of "09" which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code.
407-D7 (Product/Service ID) Enter an applicable procedure code listed in Table B and/or C. Up to four claim lines can be submitted with one transaction.

For guidance on origin code and serial number values that must be submitted on the claim, providers can refer to the Matching Origin Codes to Correct Prescription Serial Number Within Medicaid Fee-For-Service article published in the July 2020 issue of the Medicaid Update. Additionally, the NCPDP D.0 Companion Guide can be found on the eMedNY "5010/D.0 Transaction Instructions" web page.

Billing for Immunizations of Members 19 Years of Age and Older:
For administration of multiple vaccines on the same date to members 19 years of age and older, procedure code "90471" should be used for administration of the first vaccine and "90472" for administration of any other vaccines administered on that day. One line should be billed for "90472" indicating the additional number of vaccines administered (insert quantity of 1 or 2).

Billing for Immunizations for Members Younger than 19 Years of Age:
For VFC-eligible vaccines, whether enrolled in the VFC program or not, the pharmacy would submit procedure code "90460" (administration of free vaccine) for administration of first or subsequent doses, then submit the appropriate vaccine procedure code(s) with a cost of $0.00. A system edit will ensure that, when there is an incoming claim for the administrative fee (procedure code "90460"), there is also a claim in history for a VFC-eligible vaccine procedure code, reimbursed at $0.00. If no history claim is found, then the claim will be denied for the edit 02291.

For NCPDP claims transactions that are denied for edit 02291, the corresponding Medicaid Eligibility Verification System (MEVS) Denial Reason code "738" will be returned as "History Not Found for Administrative Vaccine Claim" and NCPDP Reject code "85" "Claim Not Processed".

The following procedure codes should be billed for select influenza vaccines for those two years of age and older; pneumococcal, meningococcal, hepatitis A, hepatitis B, human papilloma virus, measles, mumps, and rubella, tetanus, diphtheria, and pertussis, and varicella vaccines for those 18 years of age and older; and zoster for those 19 years of age and older:

Procedure Code Procedure Description
90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, two dose schedule, for intramuscular use
90621 Meningococcal recombinant lipoprotein vaccine, Serogroup B, a two or three dose schedule, for intramuscular use
90632 Hepatitis A vaccine, adult dosage, for intramuscular use
90633 Hepatitis A vaccine, pediatric/adolescent dosage, two dose schedule, for intramuscular use
90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use
90651 Human papillomavirus (HPV) vaccine, types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonvalent (9Vhpv), a two or three dose schedule, for intramuscular use
90662 Influenza virus vaccine (IIV4-HD), split virus, preservative free, enhanced immunogenicity via increased antigen content, for use in individuals 65 and above, for intramuscular use
90670 Pneumococcal conjugate vaccine (PCV13), 13-valent, for intramuscular use
90671 Pneumococcal conjugate vaccine (PCV15), 15-valent, for intramuscular use
90672 Influenza virus vaccine, quadrivalent (LAIV4), live, for use in individuals two years through 49 years of age, for intranasal use
90674 Influenza virus vaccine; quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, for use in individuals two years of age and older, for intramuscular use
90677 Pneumococcal conjugate vaccine (PCV20), 20-valent, for intramuscular use
90682 Influenza virus vaccine, quadrivalent, (RIV4), derived from recombinant DNA, preservative and antibiotic free, for use in individuals 18 years of age and older, for intramuscular use
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for use in individuals 12 to 35 months, for intramuscular use
90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for use in individuals three years of age and older, for intramuscular use
90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 dosage, for use in individuals 24 through 35 months of age, for intramuscular use
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, for use in individuals three years of age and older, with preservative, for intramuscular use
90694 Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, for individuals 65 years of age and older, for intramuscular use
90707 Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use
90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for intramuscular use
90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for intramuscular use
90716 Varicella virus vaccine, live, for subcutaneous use
90732 Pneumococcal polysaccharide vaccine (PPSV23), 23-valent, adult, or immunosuppressed patient dosage, for subcutaneous or intramuscular use
90734 Meningococcal conjugate vaccine, Serogroups A, C, Y and W-135 (trivalent), for intramuscular use
90739 Hepatitis B vaccine, adult dosage, two dose schedule, for intramuscular use
90740 Hepatitis B vaccine, dialysis, or immunosuppressed patient, three dose schedule, for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage, three dose schedule, for intramuscular use
90746 Hepatitis B vaccine, adult dosage, three dose schedule, for intramuscular use
90747 Hepatitis B vaccine, dialysis, or immunosuppressed patient, four dose schedule, for intramuscular use
90750 Zoster (shingles) vaccine, for use in individuals 19 years of age and older with immunocompromising conditions, for intramuscular use
90756 Influenza virus vaccine, quadrivalent (ccIIV4), antibiotic free, use in individuals two years of age and older, for intramuscular use

The following procedure codes below should be used for the actual administration of the vaccines listed above by a pharmacist:

Procedure Code Procedure Description Fee
90473 Immunization administration of seasonal influenza intranasal vaccine for ages 19 years and older. $8.57
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid). $13.23
90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure). $13.23
90460 Immunization administration of free vaccine through VFC program for members younger than 19 years of age $17.85

Vaccine Counseling

Pharmacists offering vaccine counseling services to members 18 years of age or younger can reference the coverage and reimbursement policy outlined in the Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit article published in the March 2022 issue of the Medicaid Update.

Billing Instructions for MMC Pharmacy Billing

Individual MMC Plans should be contacted for their specific reimbursement and billing guidance. Plan information can be found by visiting New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center website.

  • FFS billing questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • Managed Care Organization (MCO) billing questions should be directed to the individual MMC Plan.
  • CDC vaccine and immunization information can be found on the CDC "Vaccines & Immunizations" web page. Providers should periodically check the OTC and Supply Fee Schedule found on the eMedNY "Pharmacy Manual" web page, for updates on procedure codes found in the tables above for vaccines.

Questions and Additional Information:

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New York State Medicaid Fee-for-Service: Modifier 33 Waiving Copayment, Deductible, and Coinsurance for United States Preventive Services Task Force A and B Medical Services

The United States Preventive Services Task Force (USPSTF) A and B medical services are exempt from New York State (NYS) Medicaid fee-for-service (FFS) copayments. A listing of all the recommendations with either USPSTF A or B medical services can be found on the USPSTF "A & B Recommendations" web page.

When providing a USPSTF A or B medical service, providers should append modifier "33" to the applicable Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code when submitting the claim. Reporting modifier "33" will exempt the claim from all NYS Medicaid FFS copayments. The copayment exemption applies to clinic, ordered ambulatory, and laboratory claims. Please note: If you are billing for an Ambulatory Patient Group (APG) clinic claim, reporting modifier "33" on any claim line will exempt the entire claim from a copayment.

Questions and Additional Information:

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Pharmacy Professional Dispensing Fee Update

Effective September 22, 2022, the New York State (NYS) Medicaid fee-for-service (FFS) professional dispensing fee will change from $10.08 to $10.18 for covered outpatient drugs, when applicable. The NYS Department of Health (DOH) amended this fee to comply with the one percent across-the-board (ATB) Medicaid rate increase, which was based on the enacted budget and was effectuated by the Centers for Medicare and Medicaid Services (CMS) NYS Plan approval. Additional information on the one percent ATB Medicaid rate increase can be found on the NYS DOH "1% Across the Board (ATB) Medicaid Rate Increase" web page.

Please note: This does include retroactive adjustments to the dispensing fee back to April 1, 2022. Those adjustments will be processed at a future date; details will be forthcoming.

Questions and Additional Information:

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New York State Medicaid Expansion of Remote Patient Monitoring for Maternal Care

Effective October 1, 2022, for fee-for-service (FFS), and December 1, 2022, for Medicaid Managed Care (MMC) Plans, New York State (NYS) Medicaid is expanding coverage for remote patient monitoring (RPM) during pregnancy and up to 84 days postpartum to further improve and expand access to prenatal and postpartum care. This expansion of coverage includes an additional monthly fee to cover the cost of RPM devices/equipment.

Billing Guidance

FFS:

  • Current Procedural Terminology (CPT) Code "99091" is to be billed for the RPM service as per general NYS Medicaid telehealth guidance:
    • A minimum of 30 minutes per month must be spent collecting and interpreting NYS Medicaid member RPM data.
    • CPT Code "99091" may be billed no more than one time per member per month.
    • RPM services should be billed on the last day of each month in which RPM is delivered.
    • Federally Qualified Health Centers (FQHCs) reimbursed via the federal all-inclusive prospective payment system (PPS) rate are unable to bill for RPM services, as these services are furnished incident to an FQHC visit and, therefore, are included in the FQHC PPS rate.
  • CPT Code "99453" with HD modifier, denoting pregnant/postpartum service, may be billed once per patient per pregnancy for the initial set-up of the RPM device/equipment. CPT Code "99453" is to be used once per episode of clinical care (the time from service activation of the device/equipment to when the RPM period ends).
  • CPT Code "99454" with an HD modifier, denoting pregnant/postpartum services, may be billed once per 30-day period when the provider supplies and uses a medical device/equipment to remotely monitor and collect patient-generated health data during the member's pregnancy and/or the post-partum period(s). CPT Code "99454" is billed for continuous RPM medical device supply and patient monitoring.
  • Billing CPT code "99453" and CPT code "99454" requires usage of a medical device that digitally collects and transmits 16 or more days of data every 30 days.
  • CPT Code "99454" is billed along with CPT Code "99091".
CPT Code Description Fee
99091 Collection and interpretation of physiologic data [e.g., electrocardiogram (ECG), blood pressure, glucose monitoring] digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days. $48.00
99453 + HD
(maternal service) modifier
Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. $14.85
99454 + HD
(maternal service) modifier
Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
Every 30 days when a minimum of 16 days of data is collected within the 30-day period. This is a once per 30-day fee regardless of the number of devices used to monitor the pregnant/post-partum individual. To be billed with CPT Code "99091".
$43.23

MMC
Providers participating in MMC are to consult with the individual MMC Plans to determine how each MMC Plan will implement this policy.

Reminders:

  • The device(s) must be ordered and billed by a provider enrolled in NYS Medicaid.
  • Participating providers can contract with an outside vendor for RPM equipment; however, the NYS Medicaid-enrolled provider must bill NYS Medicaid directly.
  • Providers should not bill NYS Medicaid for non-compliant members or equipment/devices and/or monitoring covered by another funding source.
  • Appropriate records must be maintained for audit purposes.
  • This expanded coverage for RPM to include device supply with daily recording is separate and distinct from coverage for Healthcare Common Procedure Coding System (HCPCS) code A4670 - Automatic Blood Pressure Monitor Coverage Criteria. Devices covered by CPT Codes "99453" and "99454" are medical devices as defined by the Food and Drug Administration (FDA) and are fully configured for RPM.

Questions and Additional Information:

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New York State Medicaid Pharmacy Coverage of Polio Vaccine

Effective September 9, 2022 through October 9, 2022, or any subsequent extensions, and in accordance with New York State (NYS) Governor Kathy Hochul's Executive Order No. 21, NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans cover the inactivated poliovirus vaccine (IPV) for administration of IPV to Medicaid FFS members and MMC enrollees.

FFS Pharmacy Billing Guidance

The NYS FFS Medicaid program provides reimbursement to NYS Medicaid-enrolled pharmacies for IPV vaccine administration and the acquisition cost. Pharmacies should not seek reimbursement for the IPV vaccine when acquired at no cost. Pharmacies should submit a claim using the National Council for Prescription Drug Program (NCPDP) D.0 format described below.

Please note: National Drug Codes (NDCs) are not to be used for billing the vaccine product to NYS Medicaid FFS. No dispensing fee or enrollee copayment applies.

Billing Instructions:

Code Code Description
90713 IPV for subcutaneous or intramuscular use
  • Medicaid members 19 years of age and older:
    • Submit the procedure code "90471" for vaccine administration in field 407-D7 [Product/Service Identification (ID)].
    • Submit procedure code "90713" for the vaccine in field 407-D7 (Product/Service ID) with a value of $0.00 in field 409-D9 (Ingredient Cost Submitted) if the vaccine is provided at no cost.
  • Medicaid members 18 years of age:
    • Patients younger than 19 years of age and enrolled in NYS Medicaid must receive their vaccines through the Vaccines for Children (VFC) program. VFC vaccines are provided through a VFC healthcare practice or clinic. Pharmacies that choose to provide IPV to members eligible for the VFC program may provide IPV at no cost to the member or to NYS Medicaid and will be reimbursed the administration fee only by submitting the procedure code "90713" with a cost of $0.00, and the administration procedure code "90460" in field 407-D7 (Product/Service ID). Pharmacies that bill NYS Medicaid for the cost of vaccines that are available through the VFC Program are subject to recovery of payment.
NCPDP D.0. Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code
407-D7 (Product/Service ID) Enter the applicable procedure codes listed above
442-E7 (Quantity Dispensed) Enter the value of "1" for the procedure administration code
405-D5 (Day Supply) Enter the value of "1"
411-DB (Prescriber ID) Enter prescriber NPI number

For guidance on origin code and serial number values that must be submitted on the claim, providers should refer to the Matching Origin Codes to Correct Prescription Serial Number Within Medicaid Fee-for-Service (FFS) article published in the July 2020 issue of the Medicaid Update.

Vaccine Counseling

As a reminder, providers offering vaccine counseling services to members 18 years of age or younger should follow the coverage and reimbursement policy outlined in the Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit article published in the March 2022 issue of the Medicaid Update.

Medical FFS Billing Guidance

For other provider type billing guidance, providers should refer to the New York State Medicaid Polio Vaccine Coverage article published in the August 2022 issue of the Medicaid Update.

MMC Providers

NYS MMC providers must contact the Medicaid MMC enrollee's individual plan for specific billing instructions for vaccines, vaccine administration, and vaccine counseling services.

Questions and Additional Information:

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New York State Medicaid Reimbursement for Gambling Disorder Treatment Provided by Office of Addiction Services and Supports Certified Programs

Effective January 1, 2023, New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans will begin covering Gambling Disorder treatment provided to individuals receiving services from the Office of Addiction Services and Supports (OASAS) certified programs listed below.

Outpatient:

  • OASAS Certified Title 14 New York Codes, Rules, and Regulations (NYCRR) Part 822 Outpatient Clinic Programs, with a problem gambling designation.
  • OASAS Certified Title 14 NYCRR Part 825 Integrated Outpatient Services Programs, with the OASAS gambling designation.

Please note: Programs will submit claims using the 837I claim form, which is the same as the prevailing outpatient substance use disorder (SUD) treatment reimbursement and follows the Ambulatory Patient Group (APG) methodology. The OASAS Ambulatory Patient Groups (APG) Clinical and Medicaid Billing Guidance, will be updated to incorporate the appropriate references to acknowledge reimbursement for individuals with a primary gambling diagnosis. These services may be delivered face to face on-site at the certified location, via telehealth, and in the community.

Inpatient

OASAS Certified Title 14 NYCRR Part 818 Inpatient Rehabilitation Programs

Residential

OASAS Certified Title 14 NYCRR Part 820 Residential Treatment Programs

Please note: For individuals not enrolled in an MMC Plan, the claims should be submitted to Medicaid FFS. For individuals enrolled in an MMC Plan, the claim must be submitted to the enrollee's MMC Plan, and the program must be part of the MMC Plan contracted network of providers.

Questions and Additional Information:

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The Medicaid Update is a monthly publication of the New York State Department of Health.

Kathy Hochul
Governor
State of New York

Mary T. Bassett, M.D., M.P.H.
Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs