Description:
This policy addresses reimbursement guidelines for vaccines provided at no cost to the provider by a state or federal agency.
Definitions:
SL Modifier – State supplied vaccine
Policy:
Blue Cross Blue Shield of North Dakota (BCBSND) does not reimburse for vaccine(s) obtained at no cost to the provider. Modifier SL must be used to identify the vaccine(s) was obtained at no cost to the provider. BCBSND will reimburse for the administration of the vaccine(s) in accordance with the patient’s benefit coverage. Administration codes include vaccine risk/benefit counseling when performed. Therefore, a separate Evaluation and Management (E/M) code should not be reported, unless performed as a separately identifiable service distinct from the vaccine administration and documented in the medical records. E/M services submitted as separately identifiable and distinct from the administration service should be reported with modifier 25 appended to the line.
BCBSND Billing Guidelines for vaccines:
Billing Example 1: Member receives only State Issued Vaccines
1. Procedure codes for the vaccine and the vaccine administration should be submitted on the same claim.
2. State Issued Vaccine Code – Report the vaccine using the appropriate procedure code(s) and apply modifier SL for the vaccines administered and a charge of $0.
3. State Issued Vaccine Administration Code – Report the administration service(s) with the appropriate CPT code(s) that accurately reflects the administration of the state issued vaccine(s).
Billing Example 2: Member receives a State Issued Vaccine and a Vaccine that is not State Issued on same date of service
1. Codes for the vaccines and the vaccine administration should be submitted on the same claim.
2. State Issued Vaccine Code – Report vaccine using the appropriate procedure code(s) and apply modifier SL and a charge of $0.
3. State Issued Vaccine Administration Code – Report the vaccine administration with the appropriate CPT code that accurately reflects the administration of the state issued vaccine(s).
4. Vaccine Not State Issued – Report vaccine using the appropriate procedure code(s).
5. Administration Code for Vaccines Not State Issued – Report the administration with the appropriate CPT code(s) that accurately reflects the administration of the state issued vaccine(s).
Please reference the COVID-19 Resources for Providers for the most up to date information regarding billing and coding guidelines for COVID-19.
Note: If there is a system limitation that does not allow a charge to be submitted as $0, a charge of $0.01 can be billed for the state supplied vaccine.
Cross Reference:
North Dakota Department of Health Vaccines For Children (VFC) Questions and Answers
History:
Date
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Updates
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11/17/2020
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Created Modifier SL- State Supplied Vaccinations policy
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12/7/2020
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The effective date of this policy was revised to December 7, 2020 to accommodate the release of the COVID-19 vaccine. This policy will apply to claims processed on or after December 7, 2020.
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1/6/2021
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Added example of how to bill for the Coronavirus vaccine.
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1/20/2021
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Changes were made to reflect submitting a charge of $0 instead of $0.01 for state supplied vaccines and specific CPT codes were removed as codes have been changing often. Claims should be submitted with the most appropriate code for the vaccine administered.
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2/8/2021
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Updated the policy to advise a charge of $0.01 can be billed in circumstances where there is a system limitation that does not allow a charge of $0 to be billed.
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3/17/2021
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Updated billing examples to show that the vaccine and administration codes should be billed on the same claim, however, it is not required.
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9/22/2021
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Added a statement regarding billing E/M codes with vaccine administration.
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