If you are a pediatrician that provides vaccination counseling for patients under 18 years of age and younger then this blog post is for you!
The following is a clarification on the proper coding and billing for or provider reimbursement for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.
This reimbursement policy applies to Medicaid members (Empire BCBS).
Note: Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)
The following is the correct CPT code with the ICD-10 code that the providers would use in order to get proper reimbursement.
CPT 99401DX: Z71.85
A provider submitting professional claims should bill Current Procedure Terminology (CPT) code 99401 for preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required and recommended for ages 18 years or younger.
via Empire BCBS Medicaid Updates
Documentation requirements: In order to get paid for the above mentioned code, the providers need to document the following in either the medical record or a pharmacy record.
CPT 99402: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure).
Providers should bill CPT 99402 with ICD-10 code Z71.85.
Confirm vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible.
Providers are encouraged to counsel all members who have not already have an appointment scheduled to receive the vaccine dose for which they are being counseled.
If you are a physician prescribing Farxiga for any of your patients that have NY MVP Medicaid Coverage, this blog post is for you!
Farxiga may be considered for coverage when used for one of the applicable FDA-approved indications including:
For the reduction of heart failure hospitalizations in adults with Type 2 diabetes mellitus and established cardiovascular (CV) disease or multiple CV risk factors
For the treatment of heart failure with reduced ejection fraction (NYHA classes II to IV) to reduce the risk of cardiovascular death and hospitalization for heart failure
For the treatment of chronic kidney disease to reduce the risk of sustained eGFR decline, endstage kidney disease, cardiovascular death, and hospitalization for heart failure in those at-risk of disease progression
There are 2 other medications that are on the MVP Formulary that do not require prior authorization (such as Segluromet and Steglatro).
If the patient requires Farxiga then the physician needs to obtain a prior authorization.
Please follow the steps: (ALL requests have to have documentation submitted to support the use of Farxiga)
A. Visit mvphealthcare.com/Providers and Sign In to your Provider online account to use the new electronic prior authorization tool powered by Novologix®. B. Complete the appropriate MVP prior authorization form, which can be accessed at mvphealthcare.com/Providers, then select Forms, then under Prior Authorization, select the appropriate form in the Pharmacy section. Then, fax completed request form to MVP at 1-800-376-6373. C. Submit a request through Surescripts.com or CoverMyMeds.com. ( covermymeds is also available on NAVINET)
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