Download guidelines for provider enrollment and Medicaid-covered services (1203 KB) - July 2023
General Information for Providers Manual
Specialty Manuals and Guidelines
Refer to the General Information for Providers Manual for additional information and guidelines that may apply. It is the provider’s responsibility to ensure they are adhering to all published manuals, guidelines and other ND Medicaid sources of information.
Behavioral Health Services Provider Manual (July 2023)
Manuals
Dental Provider Manual (July 2023)
- CDT Code: D1352 (Dental Policy Guideline)
- CDT Codes Requiring Tooth Numbers/Quadrants (Excel File - Revised December 2021)
- CDT Code - D9410 House/Extended Care Facility Call (Dental Policy Guideline - Effective April 1, 2017)
- CDT Code D1354 - Silver Diamine Fluoride (Revised March 1, 2021)
- Dental Case Management (Effective July 1, 2023)
- Dental Screening and Assessment (Effective September 19, 2023)
- Documentation Requirements for Periodontal Services (January 2023)
- Health Track Orthodontia Screening Policy (Updated July 2022)
- North Dakota Dental Periodicity Schedule (Posted May 2020)
- Orthodontia and Third Party Liability Policy (Updated Feb. 2022)
- Orthodontic Transfers (Dental Policy Guideline)
- Palliative Treatment of Dental Pain (January 2023)
- Prosthodontics Policy (January 2023)
- Teledentistry Policy (July 2023)
Training
- NEW - Dental Provider Training Video - Common Errors (Total running time 39 minutes) (April 2022)
- Dental Provider Video Training - Sept. 2017 (Total running time 1:05)
- Training Materials (402kb pdf)
Family Support Services Policy and Procedures (Revised March 2018)
IMD policy (Updated June 2023)
Non-Emergency Documentation Guidelines
Published by Centers for Medicare & Medicaid Services (CMS). As the document indicates, it is a general reference and policies and procedures vary by state.
Visit website: Non-Emergency Medical Transportation Toolkit
- Nursing Facility Rate Manual (July 2023)
- RUG IV Classification Manual (July 2020)
- MDS 3.0 Submission Guidelines (May 2023)
- MDS Appeal Request Form (SFN 247)
- Basic Medicaid MDS 3.0 PowerPoint Presentation (January 2016)
- ND Nursing Facility Payment System Booklet (January 2012) - May be printed in booklet form. Choose under 'Page Scaling' in the Adobe print screen.
The department’s vendor Ascend, a Maximus company, has updated its manuals and forms. Some information is proprietary. Providers should visit Ascend’s website to access current versions of this information. The link appears below.
Visit website: Ascend PASRR/Level of Care manual and forms
For assistance, call 1-833-997-2777
Serious Mental Illness/Serious Emotional Disturbance (Updated October 1, 2022) (174kb pdf)
- ONLINE Training (April 23, 2020)
Child Welfare (Updated July 2022) (181 kb pdf)
- Visit website: ONLINE Training - Medicaid Targeted Case Management for Child Welfare Professionals
High-Risk Pregnant Women (Updated Oct. 2020) (216 kb pdf)
- Pharmacy Provider Manual (January 2023)
- Pharmacy Medical Billing Manual (July 2023)
The department’s vendor Ascend, a Maximus company, has updated its manuals and forms. Some information is proprietary. Providers should visit Ascend’s website to access current versions of this information.
Visit website: Ascend tools, forms and resources
For assistance, call 1-629-230-5034
Medicaid Coding Guidelines
CPT codes, descriptions and other data only are copyright 2023 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
Coding Guideline for Chiropractic Services
CPT® Codes:
98940 Chiropractic manipulative treatment (cmt); spinal, 1-2 regions
98941 Chiropractic manipulative treatment (cmt); spinal, 3-4 regions
98942 Chiropractic manipulative treatment (cmt); spinal, 5 regions
72020 Radiologic examination, spine, single view, specify level
72040 Radiologic examination, spine, cervical; 2 or 3 views
72050 Radiologic examination, spine, cervical; 4 or 5 views
72052 Radiologic examination, spine, cervical; 6 or more views
72070 Radiologic examination, spine, thoracic, 2 views
72072 Radiologic examination, spine, thoracic, 3 views
72074 Radiologic examination, spine, thoracic, minimum of 4 views
72080 Radiologic examination, spine, thoracolumbar, 2 views
72100 Radiologic examination, spine, lumbosacral; 2 or 3 views
72110 Radiologic examination, spine, lumbosacral; minimum of 4 views
72114 Radiologic examination, spine, lumbosacral; complete, incl bending views, min 6 views
72120 Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views
72220 Radiologic examination, sacrum, and coccyx, minimum of 2 views
Criteria for Reimbursement:
- Payment for manual manipulation of the spine is limited to one manipulation per day and may not exceed 20 manipulations per calendar year. Effective for dates of service on or after January 1, 2005, North Dakota Medicaid will allow reimbursement to chiropractors for Evaluation and Management (E/M) office and other outpatient Services – New Patient (99202-99203). These E/M services may be billed in addition to the chiropractic manipulative treatment (98940-98942) ONLY when the patient has not received any professional (face-to-face) services from the chiropractor, or another chiropractor of the same group practice, within the past three years.
- Payment for X-rays may not exceed two (2) per year and are limited to radiological examinations of the full spine; the cervical, thoracic, lumbar, and lumbosacral areas of the spine.
- Chiropractic services are billed on paper using the CMS-1500 form, or electronically using the standard 837-P HIPAA transaction.
Diagnosis Code Requirements:
- Two diagnostic codes must be listed on the claim to support medical necessity:
- The level of subluxation must be specified on the claim and must be listed as the primary diagnosis.
- The associated neuromusculoskeletal condition necessitating the treatment must also be listed as the secondary diagnosis.
ICD-10-CM Covered Diagnosis
Subluxation Codes
M99.00 Segmental and somatic dysfunction of head region
M99.01 Segmental and somatic dysfunction of cervical region
M99.02 Segmental and somatic dysfunction of thoracic region
M99.03 Segmental and somatic dysfunction of lumbar region
M99.04 Segmental and somatic dysfunction of sacral region
M99.05 Segmental and somatic dysfunction of pelvic region
Associated Neuromusculoskeletal Condition Codes
G44.1 Vascular headache, not elsewhere classified
G44.209 Tension-type headache, unspecified, not intractable
G44.219 Episodic tension-type headache, not intractable
G54.0 Brachial plexus disorders
G54.1 Lumbosacral plexus disorders
G54.2 Cervical root disorders, not elsewhere classified
G54.3 Thoracic root disorders, not elsewhere classified
G54.4 Lumbosacral root disorders, not elsewhere classified
G54.8 Other nerve root and plexus disorders
G55 Nerve root and plexus compressions in diseases classified elsewhere
M24.50 Contracture, unspecified joint
M25.50 Pain in unspecified joint
M43.01 Spondylolysis, occipito-atlanto-axial region
M43.02 Spondylolysis, cervical region
M43.03 Spondylolysis, cervicothoracic region
M43.04 Spondylolysis, thoracic region
M43.05 Spondylolysis, thoracolumbar region
M43.06 Spondylolysis, lumbar region
M43.07 Spondylolysis, lumbosacral region
M43.08 Spondylolysis, sacral and sacrococcygeal region
M43.09 Spondylolysis, multiple sites in spine
M43.10 Spondylolisthesis, site unspecified
M43.11 Spondylolisthesis, occipito-atlanto-axial region
M43.12 Spondylolisthesis, cervical region
M43.13 Spondylolisthesis, cervicothoracic region
M43.14 Spondylolisthesis, thoracic region
M43.15 Spondylolisthesis, thoracolumbar region
M43.16 Spondylolisthesis, lumbar region
M43.17 Spondylolisthesis, lumbosacral region
M43.18 Spondylolisthesis, sacral and sacrococcygeal region
M43.19 Spondylolisthesis, multiple sites in spine
M43.20 Fusion of spine, site unspecified
M43.21 Fusion of spine, occipito-atlanto-axial region
M43.22 Fusion of spine, cervical region
M43.23 Fusion of spine, cervicothoracic region
M43.24 Fusion of spine, thoracic region
M43.25 Fusion of spine, thoracolumbar region
M43.26 Fusion of spine, lumbar region
M43.27 Fusion of spine, lumbosacral region
M43.28 Fusion of spine, sacral and sacrococcygeal region
M43.6 Torticollis
M43.8X9 Other specified deforming dorsopathies, site unspecified
M46.01 Spinal enthesopathy, occipito-atlanto-axial region
M46.02 Spinal enthesopathy, cervical region
M46.03 Spinal enthesopathy, cervicothoracic region
M46.04 Spinal enthesopathy, lumbar region
M46.05 Spinal enthesopathy, thoracolumbar region
M46.06 Spinal enthesopathy, lumbar region
M46.07 Spinal enthesopathy, lumbosacral region
M46.08 Spinal enthesopathy, sacral and sacrococcygeal region
M46.09 Spinal enthesopathy, multiple sites in spine
M47.10 Other spondylosis with myelopathy, site unspecified
M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.24 Other spondylosis with radiculopathy, thoracic region
M47.25 Other spondylosis with radiculopathy, thoracolumbar region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M47.819 Spondylosis without myelopathy or radiculopathy, site unspecified
M47.891 Other spondylosis, occipito-atlanto-axial region
M47.892 Other spondylosis, cervical region
M47.893 Other spondylosis, cervicothoracic region
M47.894 Other spondylosis, thoracic region
M47.895 Other spondylosis, thoracolumbar region
M47.896 Other spondylosis, lumbar region
M47.897 Other spondylosis, lumbosacral region
M47.898 Other spondylosis, sacral and sacrococcygeal region
M48.01 Spinal stenosis, occipito-atlanto-axial region
M48.02 Spinal stenosis, cervical region
M48.03 Spinal stenosis, cervicothoracic region
M48.04 Spinal stenosis, thoracic region
M48.05 Spinal stenosis, thoracolumbar region
M48.06 Spinal stenosis, lumbar region
M48.07 Spinal stenosis, lumbosacral region
M48.10 Ankylosing hyperostosis [Forestier], site unspecified
M48.11 Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region
M48.12 Ankylosing hyperostosis [Forestier], cervical region
M48.13 Ankylosing hyperostosis [Forestier], cervicothoracic region
M48.14 Ankylosing hyperostosis [Forestier], thoracic region
M48.15 Ankylosing hyperostosis [Forestier], thoracolumbar region
M48.16 Ankylosing hyperostosis [Forestier], lumbar region
M48.17 Ankylosing hyperostosis [Forestier], lumbosacral region
M48.18 Ankylosing hyperostosis [Forestier], sacral and sacrococcygeal region
M48.19 Ankylosing hyperostosis [Forestier], multiple sites in spine
M48.31 Traumatic spondylopathy, occipito-atlanto-axial region
M48.32 Traumatic spondylopathy, cervical region
M48.33 Traumatic spondylopathy, cervicothoracic region
M48.34 Traumatic spondylopathy, thoracic region
M48.35 Traumatic spondylopathy, thoracolumbar region
M48.36 Traumatic spondylopathy, lumbar region
M48.37 Traumatic spondylopathy, lumbosacral region
M48.38 Traumatic spondylopathy, sacral and sacrococcygeal region
M50.00 Cervical disc disorder with myelopathy, unspecified cervical region
M50.01 Cervical disc disorder with myelopathy, high cervical region
M50.020 Cervical disc disorder with myelopathy, mid-cervical region, unspecified level
M50.021 Cervical disc disorder at C4-C5 level with myelopathy
M50.022 Cervical disc disorder at C5-C6 level with myelopathy
M50.023 Cervical disc disorder at C6-C7 level with myelopathy
M50.03 Cervical disc disorder with myelopathy, cervicothoracic region
M50.10 Cervical disc disorder with radiculopathy, unspecified cervical region
M50.11 Cervical disc disorder with radiculopathy, high cervical region
M50.120 Mid-cervical disc disorder, unspecified
M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region
M50.20 Other cervical disc displacement, unspecified cervical region
M50.21 Other cervical disc displacement, high cervical region
M50.220 Other cervical disc displacement, mid-cervical region, unspecified level
M50.221 Other cervical disc displacement at C4-C5 level
M50.222 Other cervical disc displacement at C5-C6 level
M50.223 Other cervical disc displacement at C6-C7 level
M50.23 Other cervical disc displacement, cervicothoracic region
M50.30 Other cervical disc degeneration, unspecified cervical region
M50.31 Other cervical disc degeneration, high cervical region
M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level
M50.321 Other cervical disc degeneration at C4-C5 level
M50.322 Other cervical disc degeneration at C5-C6 level
M50.323 Other cervical disc degeneration at C6-C7 level
M50.33 Other cervical disc degeneration, cervicothoracic region
M50.820 Other cervical disc disorders, mid-cervical region, unspecified level
M50.821 Other cervical disc disorders at C4-C5 level
M50.822 Other cervical disc disorders at C5-C6 level
M50.823 Other cervical disc disorders at C6-C7 level
M50.83 Other cervical disc disorders, cervicothoracic region
M50.90 Cervical disc disorder, unspecified, unspecified cervical region
M50.91 Cervical disc disorder, unspecified, high cervical region
M50.920 Unspecified cervical disc disorder, mid-cervical region, unspecified level
M50.921 Unspecified cervical disc disorder at C4-C5 level
M50.922 Unspecified cervical disc disorder at C5-C6 level
M50.923 Unspecified cervical disc disorder at C6-C7 level
M50.93 Cervical disc disorder, unspecified, cervicothoracic region
M51.06 Intervertebral disc disorders with myelopathy, lumbar region
M51.14 Intervertebral disc disorders with radiculopathy, thoracic region
M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region
M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
M51.24 Other intervertebral disc displacement, thoracic region
M51.25 Other intervertebral disc displacement, thoracolumbar region
M51.26 Other intervertebral disc displacement, lumbar region
M51.27 Other intervertebral disc displacement, lumbosacral region
M51.34 Other intervertebral disc degeneration, thoracic region
M51.35 Other intervertebral disc degeneration, thoracolumbar region
M51.36 Other intervertebral disc degeneration, lumbar region
M51.37 Other intervertebral disc degeneration, lumbosacral region
M51.84 Other intervertebral disc disorders, thoracic region
M51.85 Other intervertebral disc disorders, thoracolumbar region
M51.86 Other intervertebral disc disorders, lumbar region
M53.0 Cervicocranial syndrome
M53.1 Cervicobrachial syndrome
M53.2X7 Spinal instabilities, lumbosacral region
M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
M53.3 Sacrococcygeal disorders, not elsewhere classified
M53.80 Other specified dorsopathies, site unspecified
M53.81 Other specified dorsopathies, occipito-atlanto-axial region
M53.82 Other specified dorsopathies, cervical region
M53.83 Other specified dorsopathies, cervicothoracic region
M53.84 Other specified dorsopathies, thoracic region
M53.85 Other specified dorsopathies, thoracolumbar region
M53.86 Other specified dorsopathies, lumbar region
M53.87 Other specified dorsopathies, lumbosacral region
M53.88 Other specified dorsopathies, sacral and sacrococcygeal region
M53.9 Cervicocranial syndrome
M54.11 Radiculopathy, occipito-atlanto-axial region
M54.12 Radiculopathy, cervical region
M54.13 Radiculopathy, cervicothoracic region
M54.14 Radiculopathy, thoracic region
M54.15 Radiculopathy, thoracolumbar region
M54.16 Radiculopathy, lumbar region
M54.17 Radiculopathy, lumbosacral region
M54.2 Cervicalgia
M54.30 Sciatica, unspecified site
M54.31 Sciatica, right side
M54.32 Sciatica, left side
M54.40 Lumbago with sciatica, unspecified side
M54.41 Lumbago with sciatica, right side
M54.42 Lumbago with sciatica, left side
M54.50 Low back pain, unspecified
M54.51 Vetebrogenic low back pain
M54.59 Other low back pain
M54.6 Pain in thoracic spine
M54.81 Occipital neuralgia
M54.89 Other dorsalgia
M54.9 Dorsalgia, unspecified
M60.811 Other myositis, right shoulder
M60.812 Other myositis, left shoulder
M60.821 Other myositis, right upper arm
M60.822 Other myositis, left upper arm
M60.831 Other myositis, right forearm
M60.832 Other myositis, left forearm
M60.841 Other myositis, right hand
M60.842 Other myositis, left hand
M60.851 Other myositis, right thigh
M60.852 Other myositis, left thigh
M60.861 Other myositis, right lower leg
M60.862 Other myositis, left lower leg
M60.871 Other myositis, right ankle and foot
M60.872 Other myositis, left ankle and foot
M60.89 Other myositis, multiple sites
M60.9 Myositis, unspecified
M62.830 Muscle spasm of back
M79.10 Myalgia, unspecified site
M79.11 Myalgia of mastication muscle
M79.12 Myalgia of auxiliary muscles, head and neck
M79.18 Myalgia, other site
M79.7 Fibromyalgia
M96.1 Post-laminectomy syndrome, not elsewhere classified
M99.20 Subluxation stenosis of neural canal of head region
M99.21 Subluxation stenosis of neural canal of cervical region
M99.22 Subluxation stenosis of neural canal of thoracic region
M99.23 Subluxation stenosis of neural canal of lumbar region
M99.30 Osseous stenosis of neural canal of head region
M99.31 Osseous stenosis of neural canal of cervical region
M99.32 Osseous stenosis of neural canal of thoracic region
M99.33 Osseous stenosis of neural canal of lumbar region
M99.40 Connective tissue stenosis of neural canal of head region
M99.41 Connective tissue stenosis of neural canal of cervical region
M99.42 Connective tissue stenosis of neural canal of thoracic region
M99.43 Connective tissue stenosis of neural canal of lumbar region
M99.50 Intervertebral disc stenosis of neural canal of head region
M99.51 Intervertebral disc stenosis of neural canal of cervical region
M99.52 Intervertebral disc stenosis of neural canal of thoracic region
M99.53 Intervertebral disc stenosis of neural canal of lumbar region
M99.60 Osseous and subluxation stenosis of intervertebral foramina of head region
M99.61 Osseous and subluxation stenosis of intervertebral foramina of cervical region
M99.62 Osseous and subluxation stenosis of intervertebral foramina of thoracic region
M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region
M99.70 Connective tissue and disc stenosis of intervertebral foramina of head region
M99.71 Connective tissue and disc stenosis of intervertebral foramina of cervical region
M99.72 Connective tissue and disc stenosis of intervertebral foramina of thoracic region
M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region
N47.27 Connective tissue and disc stenosis of intervertebral foramina of thoracic region
Q76.2 Congenital spondylolisthesis
R51.0 Headache with orthostatic component, not elsewhere classified
R51.9 Headache, unspecified
S13.4XXA Sprain of ligaments of cervical spine, initial encounter
S13.4XXD Sprain of ligaments of cervical spine, subsequent encounter
S13.4XXS Sprain of ligaments of cervical spine, sequela
S13.8XXA Sprain of joints and ligaments of other parts of neck, initial encounter
S13.8XXD Sprain of joints and ligaments of other parts of neck, subsequent encounter
S13.8XXS Sprain of the other specified parts of the thorax, initial encounter
S16.1XXA Sprain of ligaments of thoracic spine, initial encounter
S16.1XXD Strain of muscle, fascia and tendon at neck level, subsequent encounter
S16.1XXS Strain of muscle, fascia and tendon at neck level, sequela
S23.3XXA Sprain of ligaments of thoracic spine, initial encounter
S23.3XXD Sprain of ligaments of thoracic spine, subsequent encounter
S23.3XXS Sprain of ligaments of thoracic spine, sequela
S23.8XXA Sprain of other specified parts of thorax, initial encounter
S23.8XXD Sprain of other specified parts of thorax, subsequent encounter
S23.8XXS Sprain of other specified parts of thorax, sequela
S33.5XXA Sprain of ligaments of lumbar spine, initial encounter
S33.5XXD Sprain of ligaments of lumbar spine, subsequent encounter
S33.5XXS Sprain of ligaments of lumbar spine, sequela
S33.6XXA Sprain of ligaments of lumbar spine, initial encounter
S33.6XXD Sprain of sacroiliac joint, subsequent encounter
S33.6XXS Sprain of sacroiliac joint, sequela
S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter
S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent encounter
S33.8XXS Sprain of other parts of lumbar spine and pelvis, sequela
S39.012A Strain of muscle, fascia and tendon of lower back, initial encounter
S39.012D Strain of muscle, fascia and tendon of lower back, subsequent encounter
S39.012S Strain of muscle, fascia and tendon of lower back, sequela
________________________________________
Created: October 2002
Updated: March 2004, February 2010, June 2015, October 2016, July 2019 (format), July 2023
Coding Guideline for Developmental Screenings and Brief Behavioral Assessments
CPT© Code: 96110
Developmental screen (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument
CPT© Code: 96127
Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
Criteria for Coverage
ND Medicaid allows these services when billed in conjunction with a preventative medicine service, Evaluation and Management service, or EPSDT service. Code 96110 should be used to report screening for healthy, physical development (speech and language development, physical growth). Code 96127 should be used to report a brief assessment for ADHD, depression, suicidal risk, anxiety, substance abuse, eating disorders, etc. This code was created in response to the Affordable Care Act’s federal mandate to include mental health services as part of the essential benefits that must be included in all insurance plans offered in individual and small group markets. The mandate covers services such as depression screening for adolescents, alcohol and drug use in adolescents, and behavioral assessments in children and adolescents.
ND Medicaid aligns with the American Academy of Pediatrics (AAP) Bright Futures guidelines which include the following screening tools: For more information refer to Bright Futures Toolkit: Links to Commonly Used Screening Instruments and Tools | AAP Toolkits | American Academy of Pediatrics
|
Instrument |
Abbreviation |
CPT code |
|
Ages and Stages Questionnaire - Third Edition |
ASQ-3 |
96110 |
|
Ages and Stages Questionnaire: Social-Emotional 2nd Edition |
ASQ:SE-2 |
96127 |
|
Ask Suicide-Screening Questions |
ASQ |
96127 |
|
Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide |
(No Abbreviation) |
96127 |
|
Baby Pediatric Symptoms Checklist |
BBSC |
96127 |
|
Brief Screener for Alcohol, Tobacco, and Other Drugs |
BSTAD |
96127 |
|
Columbia -Suicide Severity Rating Scale |
C-SSRS |
96127 |
|
Modified Checklist for Autism in Toddlers |
M-CHAT or M-CHAT-R/F |
96110 |
|
Patient Health Questionnaire |
PHQ-2, PHQ-9 or PHQ-A |
96127 |
|
Patient Safety Screener |
PSS-3 |
96127 |
|
Parents' Evaluation of Developmental Status |
PEDS |
96110 |
|
Pediatric Symptom Checklist |
PSC, PSC-Y or PSC-17 |
96127 |
|
Preschool Pediatric Symptoms Checklist |
PPSC |
96127 |
|
Screening to Brief Intervention |
S2BI |
96127 |
|
Strength and Difficulties Questionnaire |
SDQ |
96127 |
|
Car, Relax, Alone, Forget, Friends, Trouble |
CRAFFT |
96127 |
|
Survey of Well-being of Young Children |
SWYC |
96110 |
Created: January 2015
Updated: December 2018; October 2019 (format only) August 2022
Coding Guideline for Certain Encounters for Routine and Administrative Purposes
Encounters / Services for the following ICD-10 codes are allowed under the following circumstances:
Z02.2 Encounter for examination for admission to a residential institution
- Nursing Home Admission Physical Examinations
- Annual Physicals are required for members living in an ICF/IID
Z02.89 Encounter for other administrative examinations
- Refugee/New American / Immigration Physicals
- A description of the service i.e. “refugee” or “New American” must be noted in Box 19 of the CMS 1500 or 837-P equivalent field or Box 80 of the CMS UB-04 or 837-I equivalent field
Z04.8 Encounter for examination and observation for other specified reason
- Documentation supporting medical necessity must be submitted for all claims containing this diagnosis
Non-Covered General and Administrative Services
- Occupational Health Screenings
- Pre-Employment Screenings
- DOT Physicals
- Volunteer Activity Screenings
- Medical Clearance for incarceration without an acute injury/illness/symptom
- Camp Physicals
Created: July 2017
Updated: June 2018; September 2019 (format only); September 2021
Coding Guideline for Application of Fluoride Varnish
CDT© Codes
D1206 Topical application of fluoride varnish
D1208 Topical application of fluoride – excluding varnish
99188 Application of topical fluoride varnish by a physician or other qualified health care professional when performed in a non-dental clinic of facility setting
Criteria for Reimbursement:
Children Coverage
Fluoride treatment is covered for members ages 6 months through 20 years old. A maximum of three applications per year, per member is covered. Dental offices may bill utilizing codes D1206 or D1208.
Fluoride varnish performed in a non-dental clinic or facility setting is covered for members ages 6 months through 20 years old. A maximum of two applications per year, per member is covered. Clinics and facilities may bill utilizing code 99188. It is recommended the fluoride varnish be applied at the time of a well-child visit / Health Tracks screening.
Adult Coverage
Fluoride treatment is covered for members ages 21 and older. A maximum of two applications per year, per member is covered. Dental offices may bill utilizing codes D1206 or D1208.
|
D1206 |
D1208 |
99188 |
|
|
Children |
3/year *shared with D1208 |
3/year *shared with D1206 |
2/year *separate limit |
|
Adults |
2/year *shared with D1208 |
2/year *shared with D1206 |
no coverage |
- Dentists, physicians, and physician assistants may bill ND Medicaid for the application of fluoride varnish in accordance with their scope of practice and in accordance with any rules adopted by their respective licensing boards.
- The following practitioners may bill ND Medicaid for the application of fluoride varnish after receiving training that has been approved by the North Dakota Board of Dental Examiners:
- Nurse Practitioners
- Registered Nurses and Licensed Practical Nurses under the supervision* of a physician, family nurse practitioner, or physician assistant
- Registered Dental Hygienist or Registered Dental Assistant under the supervision* of a licensed dentist.
*Supervision requirements are dictated by state law, administrative rules, and the applicable licensing boards.
ICD-10-CM Covered Diagnosis
Z00.121 Encounter for routine child health examination with abnormal findings
Z00.129 Encounter for routine child health examination without abnormal findings
Z29.3 Encounter for prophylactic fluoride administration
Z41.8 Encounter for other procedures for purposes other than remedying health state
Additional Resources
Benefits of Fluoride Varnish FAQ
Inform Sheet: Dental Fluoride Varnish Comparison
Created: July 2007
Updated: January 2013; May 2015, August 2017; July 2018, July 2019, August 2020; April 2021; October 2021; November 2022
Coding Guideline for HIV Screening
HCPCS©/ CPT© Codes
G0432 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and / or HIV-2, screening
G0433 Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening
G0435 Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening
G0475 HIV antigen/antibody, combination assay, screening 80081 Obstetric panel (includes HIV testing)
Criteria for Coverage
Members must meet one of the following:
- Be at increased risk for HIV infection
- Anyone who asks for a test
- Pregnant woman
Frequency of Screening
- Annually for members between 15 - 65 years without regard to perceived risk
- Annually for members under 15 years and adults older than 65 who are at increased risk for HIV infection:
- Men who have sex with men
- Men and women having unprotected vaginal or anal intercourse
- Past of present injection drug users
- Men and women who exchange sex for money or drugs or have sex partners who do
- Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users,
- Persons who have acquired or request testing for other sexually transmitted infectious diseases,
- Persons with a history of blood transfusions between 1978 and 1985,
- Persons who request an HIV test despite reporting no individual risk factors,
- Persons with new sexual partners,
- Persons who, based on individualized physician interview and examination
- Pregnant members covered three times during pregnancy
- When diagnosed as pregnant
- During the third trimester
- At labor, if ordered by a clinician
ICD-10-CM Code Requirements
Increased risk factors not reported
- Z11.4 – Encounter for screening for human immunodeficiency virus
Increased risk factors reported
- Z11.4 – Encounter for screening for human immunodeficiency virus; and
- Z72.89 – Other problems related to lifestyle
- Z72.51 – High-risk heterosexual behavior
- Z72.52 – High-risk homosexual behavior; or
- Z72.53 – High-risk bisexual behavior
Pregnant Medicaid Members
- Z11.4 – Encounter for screening for human immunodeficiency virus; and
- Z34.00 – Encounter for supervision of normal first pregnancy, unspecified trimester
- Z34.01 – Encounter for supervision of normal first pregnancy, first trimester
- Z34.02 – Encounter for supervision of normal first pregnancy, second trimester
- Z34.03 – Encounter for supervision of normal first pregnancy, third trimester
- Z34.80 – Encounter for supervision of other normal pregnancy, unspecified trimester
- Z34.81 – Encounter for supervision of other normal pregnancy, first trimester
- Z34.82 – Encounter for supervision of other normal pregnancy, second trimester
- Z34.83 – Encounter for supervision of other normal pregnancy, third trimester
- Z34.90 – Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
- Z34.91 – Encounter for supervision of normal pregnancy, unspecified, first trimester
- Z34.92 – Encounter for supervision of normal pregnancy, unspecified, second trimester
- Z34.93 – Encounter for supervision of normal pregnancy, unspecified, third trimester
- O09.90 – Supervision of high-risk pregnancy, unspecified, unspecified trimester
- O09.91 – Supervision of high-risk pregnancy, unspecified, first trimester
- O09.92 – Supervision of high-risk pregnancy, unspecified, second trimester; or
- O09.93 – Supervision of high-risk pregnancy, unspecified, third trimester
Created: April 2020
Coding Guideline for Maternal Depression Screening
CPT© Code: 96161
Administration of a caregiver-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument
Indications
Maternal depression affects up to 18% of mothers during the first year after delivery. Untreated maternal depression can have major, long-term adverse effects on the mother and her child, including placing the child at risk for delays in social-emotional development. Early detection, referral, and treatment of maternal depression can greatly reduce adverse consequences. A pediatric provider may be the only provider that a mother sees within the first year after delivery. As a result, pediatric providers can identify and refer mothers for depression through routine screening at the child’s Health Tracks (EPSDT) screening, Well-Child Check, or other pediatric office visits.
Effective July 1, 2011, North Dakota Medicaid reimburses maternal depression screening as a separate service when performed in conjunction with a Health Tracks screening, Well-Child Check, or any other pediatric visit, as a risk assessment for the child. Providers are encouraged to screen mothers who have a North Dakota Medicaid-eligible child under the age of one for maternal depression.
Criteria for Coverage
- Screen any time within the child’s first year
- American Academy of Pediatrics – Bright Futures guidelines recommend screening at the 1-month visit, 2-month visit, 4-month visit, and 6-month visit. For more information refer to Bright Futures Toolkit: Links to Commonly Used Screening Instruments and Tools
- Use one of the following standardized screening tools:
- Edinburgh Postnatal Depression Scale (EPDS)
- Patient Health Questionnaire - 9 (PHQ-9) Screener
Coding Requirements
- CPT Code
- 96161 Administration of a caregiver-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument
- ICD10-CM Covered Diagnosis
- Z00.110 Health Examination for a newborn under 8 days old
- Z00.111 Health Examination for a newborn 8 to 28 days old
- Z00.121 Encounter for routine child health exam with abnormal findings
- Z00.129 Encounter for routine child health exam w/out abnormal findings
Billing Requirements
When a Maternal Depression Screening occurs during a Health Tracks screening, Well-Child Check, or other pediatric office visit for a child eligible for North Dakota Medicaid under one year of age, the following guidelines apply:
- Bill only when one of the standardized screening instruments is used
- Bill using the child’s North Dakota Medicaid recipient ID number
Limits
North Dakota Medicaid allows up to four (4) Maternal Depression Screenings for a child up to age one.
Created: July 2017
Updated: September 2019 (format only); April 2020 (screening tools); October 2022
Coding Guideline for Medical Nutrition Therapy
CPT © / HCPCS Codes:
| 97802 | Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minuites |
| 97803 | Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes |
| 97804 | Medical nutrition therapy; group (2 or more individuals); each 30 minutes |
| G0270 | Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis medical condition, or treatment regimen(including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes |
| G0271 | Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis medical condition, or treatment regimen(including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes |
Criteria for Coverage
Coverage is allowed for up to four hours per calendar year. Services must be provided by a licensed registered dietitian (LRD) or nutrition professional meeting certain requirements.
ICD10-CM Covered Diagnosis
| E11.9 | Type 2 diabetes mellitus without complications |
| E13.9 | Other specified diabetes mellitus without complications |
| E10.9 | Type 1 diabetes mellitus without complications |
| E11.65 | Type 2 diabetes mellitus with hyperglycemia |
| E10.65 | Type 1 diabetes mellitus with hyperglycemia |
| E11.69 | Type 2 diabetes mellitus with other specified complication |
| E13.10 | Other specified diabetes mellitus with ketoacidosis without coma |
| E10.10 | Type 1 diabetes mellitus with ketoacidosis without coma |
| E11.00 | Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) |
| E11.01 | Type 2 diabetes mellitus with hyperosmolarity with coma |
| E10.641 | Type 1 diabetes mellitus with hypoglycemia with coma |
| E10.69 | Type 1 diabetes mellitus with other specified complication |
| E10.8 | Type 1 diabetes mellitus with unspecified complications |
| E13.01 | Other specified diabetes mellitus with hyperosmolarity with coma |
| E11.641 | Type 2 diabetes mellitus with hypoglycemia with coma |
| E13.11 | Other specified diabetes mellitus with ketoacidosis with coma |
| E13.641 | Other specified diabetes mellitus with hypoglycemia with coma |
| E10.11 | Type 1 diabetes mellitus with ketoacidosis with coma |
| E11.21 | Type 2 diabetes mellitus with diabetic nephropathy |
| E11.22 | Type 2 diabetes mellitus with diabetic chronic kidney disease |
| E11.29 | Type 2 diabetes mellitus with other diabetic kidney complication |
| E13.21 | Other specified diabetes mellitus with diabetic nephropathy |
| E13.22 | Other specified diabetes mellitus with diabetic chronic kidney disease |
| E13.29 | Other specified diabetes mellitus with other diabetic kidney complication |
| E10.21 | Type 1 diabetes mellitus with diabetic nephropathy |
| E10.22 | Type 1 diabetes mellitus with diabetic chronic kidney disease |
| E10.29 | Type 1 diabetes mellitus with other diabetic kidney complication |
| E11.311 | Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| E11.319 | Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema |
| E11.321 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema |
| E11.329 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema |
| E11.331 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema |
| E11.339 | Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema |
| E11.341 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema |
| E11.349 | Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema |
| E11.351 | Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema |
| E11.359 | Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema |
| E11.36 | Type 2 diabetes mellitus with diabetic cataract |
| E11.39 | Type 2 diabetes mellitus with other diabetic ophthalmic complication |
| E13.311 | Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| E13.319 | Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema |
| E13.321 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema |
| E13.329 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema |
| E13.331 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema |
| E13.339 | Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema |
| E13.341 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema |
| E13.349 | Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema |
| E13.351 | Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema |
| E13.359 | Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema |
| E13.36 | Other specified diabetes mellitus with diabetic cataract |
| E13.39 | Other specified diabetes mellitus with other diabetic ophthalmic complication |
| E10.311 | Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema |
| E10.319 | Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema |
| E10.321 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema |
| E10.329 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema |
| E10.331 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema |
| E10.339 | Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema |
| E10.341 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema |
| E10.349 | Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema |
| E10.351 | Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema |
| E10.359 | Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema |
| E10.36 | Type 1 diabetes mellitus with diabetic cataract |
| E10.39 | Type 1 diabetes mellitus with other diabetic ophthalmic complication |
| E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unspecified |
| E11.41 | Type 2 diabetes mellitus with diabetic mononeuropathy |
| E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy |
| E11.43 | Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy |
| E11.44 | Type 2 diabetes mellitus with diabetic amyotrophy |
| E11.49 | Type 2 diabetes mellitus with other diabetic neurological complication |
| E11.610 | Type 2 diabetes mellitus with diabetic neuropathic arthropathy |
| E13.40 | Other specified diabetes mellitus with diabetic neuropathy, unspecified |
| E13.41 | Other specified diabetes mellitus with diabetic mononeuropathy |
| E13.42 | Other specified diabetes mellitus with diabetic polyneuropathy |
| E13.43 | Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy |
| E13.44 | Other specified diabetes mellitus with diabetic amyotrophy |
| E13.49 | Other specified diabetes mellitus with other diabetic neurological complication |
| E13.610 | Other specified diabetes mellitus with diabetic neuropathic arthropathy |
| E10.40 | Type 1 diabetes mellitus with diabetic neuropathy, unspecified |
| E10.41 | Type 1 diabetes mellitus with diabetic mononeuropathy |
| E10.42 | Type 1 diabetes mellitus with diabetic polyneuropathy |
| E10.43 | Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy |
| E10.44 | Type 1 diabetes mellitus with diabetic amyotrophy |
| E10.49 | Type 1 diabetes mellitus with other diabetic neurological complication |
| E10.610 | Type 1 diabetes mellitus with diabetic neuropathic arthropathy |
| E11.51 | Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E11.52 | Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene |
| E11.59 | Type 2 diabetes mellitus with other circulatory complications |
| E13.51 | Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E13.52 | Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene |
| E13.59 | Other specified diabetes mellitus with other circulatory complications |
| E10.51 | Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| E10.52 | Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene |
| E10.59 | Type 1 diabetes mellitus with other circulatory complications |
| E11.618 | Type 2 diabetes mellitus with other diabetic arthropathy |
| E11.620 | Type 2 diabetes mellitus with diabetic dermatitis |
| E11.621 | Type 2 diabetes mellitus with foot ulcer |
| E11.622 | Type 2 diabetes mellitus with other skin ulcer |
| E11.628 | Type 2 diabetes mellitus with other skin complications |
| E11.630 | Type 2 diabetes mellitus with periodontal disease |
| E11.638 | Type 2 diabetes mellitus with other oral complications |
| E11.649 | Type 2 diabetes mellitus with hypoglycemia without coma |
| E13.618 | Other specified diabetes mellitus with other diabetic arthropathy |
| E13.620 | Other specified diabetes mellitus with diabetic dermatitis |
| E13.621 | Other specified diabetes mellitus with foot ulcer |
| E13.622 | Other specified diabetes mellitus with other skin ulcer |
| E13.628 | Other specified diabetes mellitus with other skin complications |
| E13.630 | Other specified diabetes mellitus with periodontal disease |
| E13.638 | Other specified diabetes mellitus with other oral complications |
| E13.649 | Other specified diabetes mellitus with hypoglycemia without coma |
| E13.65 | Other specified diabetes mellitus with hyperglycemia |
| E13.69 | Other specified diabetes mellitus with other specified complication |
| E10.618 | Type 1 diabetes mellitus with other diabetic arthropathy |
| E10.620 | Type 1 diabetes mellitus with diabetic dermatitis |
| E10.621 | Type 1 diabetes mellitus with foot ulcer |
| E10.622 | Type 1 diabetes mellitus with other skin ulcer |
| E10.628 | Type 1 diabetes mellitus with other skin complications |
| E10.630 | Type 1 diabetes mellitus with periodontal disease |
| E10.638 | Type 1 diabetes mellitus with other oral complications |
| E10.649 | Type 1 diabetes mellitus with hypoglycemia without coma |
| E11.8 | Type 2 diabetes mellitus with unspecified complications |
| E13.8 | Other specified diabetes mellitus with unspecified complications |
| E34.9 | Endocrine disorder, unspecified |
| E70.0 | Classical phenylketonuria |
| E78.0 | Pure hypercholesterolemia |
| E78.1 | Pure hyperglyceridemia |
| E78.2 | Mixed hyperlipidemia |
| E78.3 | Hyperchylomicronemia |
| E78.4 | Other hyperlipidemia |
| E78.5 | Hyperlipidemia, unspecified |
| E78.6 | Lipoprotein deficiency |
| E88.1 | Lipodystrophy, not elsewhere classified |
| E75.10 | Unspecified gangliosides |
| E75.19 | Other gangliosides |
| E75.21 | Fabry (-Anderson) disease |
| E75.22 | Gaucher disease |
| E75.240 | Niemann-Pick disease type A |
| E75.241 | Niemann-Pick disease type B |
| E75.242 | Niemann-Pick disease type C |
| E75.243 | Niemann-Pick disease type D |
| E75.248 | Other Niemann-Pick disease |
| E75.249 | Niemann-Pick disease, unspecified |
| E75.3 | Sphingolipidosis, unspecified |
| E77.0 | Defects in post-translational modification of lysosomal enzymes |
| E77.1 | Defects in glycoprotein degradation |
| E77.8 | Other disorders of glycoprotein metabolism |
| E77.9 | Disorder of glycoprotein metabolism, unspecified |
| E71.30 | Disorder of fatty-acid metabolism, unspecified |
| E75.5 | Other lipid storage disorders |
| E78.79 | Other disorders of bile acid and cholesterol metabolism |
| E78.81 | Lipoid dermatoarthritis |
| E78.89 | Other lipoprotein metabolism disorders |
| E88.2 | Lipomatosis, not elsewhere classified |
| E75.6 | Lipid storage disorder, unspecified |
| E78.70 | Disorder of bile acid and cholesterol metabolism, unspecified |
| E78.9 | Disorder of lipoprotein metabolism, unspecified |
| E66.9 | Obesity, unspecified |
| E66.01 | Morbid (severe) obesity due to excess calories |
| E66.3 | Overweight |
| E65 | Localized adiposity |
| F50.00 | Anorexia nervosa, unspecified |
| F50.01 | Anorexia nervosa, restricting type |
| F50.02 | Anorexia nervosa, binge eating/purging type |
| F50.2 | Bulimia nervosa |
| F50.8 | Other eating disorders |
| F98.29 | Other feeding disorders of infancy and early childhood |
| I10 | Essential (primary) hypertension |
| I11.9 | Hypertensive heart disease without heart failure |
| I11.0 | Hypertensive heart disease with heart failure |
| I12.9 | Hypertensive CKD with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease |
| I12.0 | Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease |
| I13.10 | Hypertensive heart and CKD without heart failure, with stage 1 through stage 4 CKD, or unspecified CKD |
| I13.0 | Hypertensive heart and CKD with heart failure and stage 1 through stage 4 CKD, or unspecified CKD |
| I13.11 | Hypertensive heart and CKD without heart failure, with stage 5 chronic kidney disease, or end stage renal disease |
| I13.2 | Hypertensive heart and CKD with heart failure and with stage 5 chronic kidney disease, or end stage renal disease |
| I15.0 | Renovascular hypertension |
| I15.8 | Other secondary hypertension |
| I15.9 | Secondary hypertension, unspecified |
| I21.09 | ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall |
| I22.0 | Subsequent ST elevation (STEMI) myocardial infarction of anterior wall |
| I21.01 | ST elevation (STEMI) myocardial infarction involving left main coronary artery |
| I21.02 | ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery |
| I21.19 | ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall |
| I22.1 | Subsequent ST elevation (STEMI) myocardial infarction of inferior wall |
| I21.11 | ST elevation (STEMI) myocardial infarction involving right coronary artery |
| I21.29 | ST elevation (STEMI) myocardial infarction involving other sites |
| I22.8 | Subsequent ST elevation (STEMI) myocardial infarction of other sites |
| I21.4 | Non-ST elevation (NSTEMI) myocardial infarction |
| I22.2 | Subsequent non-ST elevation (NSTEMI) myocardial infarction |
| I21.21 | ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery |
| I21.3 | ST elevation (STEMI) myocardial infarction of unspecified site |
| I22.9 | Subsequent ST elevation (STEMI) myocardial infarction of unspecified site |
| I24.1 | Dressler's syndrome |
| I20.0 | Unstable angina |
| I23.7 | Postinfarction angina |
| I24.0 | Acute coronary thrombosis not resulting in myocardial infarction |
| I24.8 | Other forms of acute ischemic heart disease |
| I24.9 | Acute ischemic heart disease, unspecified |
| I25.10 | Atherosclerotic heart disease of native coronary artery without angina pectoris |
| I25.110 | Atherosclerotic heart disease of native coronary artery with unstable angina pectoris |
| I25.111 | Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm |
| I25.118 | Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris |
| I25.119 | Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris |
| I25.710 | Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris |
| I25.711 | Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm |
| I25.718 | Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris |
| I25.719 | Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris |
| I25.728 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris |
| I25.729 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris |
| I25.810 | Atherosclerosis of coronary artery bypass graft(s) without angina pectoris |
| I25.730 | Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris |
| I25.731 | Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm |
| I25.738 | Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris |
| I25.739 | Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris |
| I25.720 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris |
| I25.721 | Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm |
| I25.790 | Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris |
| I25.791 | Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm |
| I25.798 | Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris |
| I25.799 | Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris |
| I25.700 | Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris |
| I25.701 | Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm |
| I25.708 | Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris |
| I25.709 | Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris |
| I25.750 | Atherosclerosis of native coronary artery of transplanted heart with unstable angina |
| I25.751 | Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm |
| I25.758 | Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris |
| I25.759 | Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris |
| I25.811 | Atherosclerosis of native coronary artery of transplanted heart without angina pectoris |
| I25.760 | Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina |
| I25.761 | Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm |
| I25.768 | Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris |
| I25.769 | Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris |
| I25.812 | Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris |
| I25.3 | Aneurysm of heart |
| I25.41 | Coronary artery aneurysm |
| I25.42 | Coronary artery dissection |
| I25.89 | Other forms of chronic ischemic heart disease |
| I25.9 | Chronic ischemic heart disease, unspecified |
| K90.0 | Celiac disease |
| N18.1 | Chronic kidney disease, stage 1 |
| N18.2 | Chronic kidney disease, stage 2 (mild) |
| N18.3 | Chronic kidney disease, stage 3 (moderate) |
| N18.4 | Chronic kidney disease, stage 4 (severe) |
| N18.5 | Chronic kidney disease, stage 5 |
| N18.6 | End stage renal disease |
| N18.9 | Chronic kidney disease, unspecified |
| O24.019 | Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester |
| O24.119 | Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester |
| O24.319 | Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester |
| O24.819 | Other pre-existing diabetes mellitus in pregnancy, unspecified trimester |
| O24.919 | Unspecified diabetes mellitus in pregnancy, unspecified trimester |
| O24.011 | Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester |
| O24.012 | Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester |
| O24.013 | Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester |
| O24.02 | Pre-existing diabetes mellitus, type 1, in childbirth |
| O24.111 | Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester |
| O24.112 | Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester |
| O24.113 | Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester |
| O24.12 | Pre-existing diabetes mellitus, type 2, in childbirth |
| O24.311 | Unspecified pre-existing diabetes mellitus in pregnancy, first trimester |
| O24.312 | Unspecified pre-existing diabetes mellitus in pregnancy, second trimester |
| O24.313 | Unspecified pre-existing diabetes mellitus in pregnancy, third trimester |
| O24.32 | Unspecified pre-existing diabetes mellitus in childbirth |
| O24.811 | Other pre-existing diabetes mellitus in pregnancy, first trimester |
| O24.812 | Other pre-existing diabetes mellitus in pregnancy, second trimester |
| O24.813 | Other pre-existing diabetes mellitus in pregnancy, third trimester |
| O24.82 | Other pre-existing diabetes mellitus in childbirth |
| O24.911 | Unspecified diabetes mellitus in pregnancy, first trimester |
| O24.912 | Unspecified diabetes mellitus in pregnancy, second trimester |
| O24.913 | Unspecified diabetes mellitus in pregnancy, third trimester |
| O24.92 | Unspecified diabetes mellitus in childbirth |
| O24.03 | Pre-existing diabetes mellitus, type 1, in the puerperium |
| O24.13 | Pre-existing diabetes mellitus, type 2, in the puerperium |
| O24.33 | Unspecified pre-existing diabetes mellitus in the puerperium |
| O24.410 | Gestational diabetes mellitus in pregnancy, diet controlled |
| O24.414 | Gestational diabetes mellitus in pregnancy, insulin controlled |
| O24.419 | Gestational diabetes mellitus in pregnancy, unspecified control |
| O24.420 | Gestational diabetes mellitus in childbirth, diet controlled |
| O24.424 | Gestational diabetes mellitus in childbirth, insulin controlled |
| O24.429 | Gestational diabetes mellitus in childbirth, unspecified control |
| O24.430 | Gestational diabetes mellitus in the puerperium, diet controlled |
| O24.434 | Gestational diabetes mellitus in the puerperium, insulin controlled |
| O24.439 | Gestational diabetes mellitus in the puerperium, unspecified control |
| O24.83 | Other pre-existing diabetes mellitus in the puerperium |
| O24.93 | Unspecified diabetes mellitus in the puerperium |
| O99.810 | Abnormal glucose complicating pregnancy |
| O99.814 | Abnormal glucose complicating childbirth |
| O99.815 | Abnormal glucose complicating the puerperium |
| R73.01 | Impaired fasting glucose |
| R73.02 | Impaired glucose tolerance (oral) |
| R73.02 | Impaired glucose tolerance (oral) |
| R73.09 | Other abnormal glucose |
| R73.9 | Hyperglycemia, unspecified |
Created: July 2017
Updated: March 2019; September 2019 (format only); June 2020
Coding Guideline for Synagis® (palivizumab)
CPT© Code: 90378
Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each
Criteria for Coverage:
Synagis® (palivizumab) will be allowed for up to five weight-based doses within six months of RSV season onset as defined by using the CDC’s National Respiratory and Enteric Virus Surveillance System (NREVSS) Midwest Region data, which can be found at: RSV Regional Trends - NREVSS | CDC. RSV season onset will be defined as the first of two consecutive weeks when the percentage of PCR tests positive for RSV is greater than 3%; season offset will be defined as the last of two consecutive weeks when the percentage of PCR tests positive for RSV is less than 3%. No further prior authorization requests will be approved following the season offset.
Patients must meet the most current AAP guidelines which can be found at: www.aap.org or Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection | From the American Academy of Pediatrics | Pediatrics
Prior Authorization:
Prior Authorization (PA) must be obtained through Kepro by completing the online Synagis PA Form. The approval letter will include the ND MMIS Service Authorization number and the number of authorized units with the duration of the approval. The ND MMIS Service Authorization Number must be entered on the claim at the time of submission. Failure to do so will result in claim denial.
Coding and Billing Instruction:
CPT© 90378 must be billed electronically via an 837P transaction with the correlating NDC code for the Synagis® administered.
Synagis® is available in both 50mg and 100 mg vials. Multiple vial dosages should be reported with the most accurate combination to reflect the actual amount of drug administered. Each unique NDC must be reported on a separate line on the 837P with the correlating number of HCPCS units.
Effective for dates of service on or after 10/19/2018 standard National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) editing will be applied to the administration code (CPT 96372) and Evaluation and Management (E/M) Service combination when rendered on the same date of service by the same provider.
Created: July 2017
Updated: October 2019 (format only), September 2022
Vaccines / Toxoids Coding Guideline
Vaccines / Toxoids
This Immunization coding guideline provides a summary of benefits and billing guidelines for North Dakota Medicaid providers who administer vaccines to children and adults. North Dakota Medicaid periodically reviews and modifies immunization benefits and services. Therefore, the information in this guideline is subject to change, and the document is updated as new policies are implemented.
ND Medicaid works to promote and facilitate the prevention of vaccine-preventable diseases. ND Medicaid works closely with the North Dakota Department of Health / Vaccine for Children Program to implement immunization recommendations by the Advisory Committee on Immunization (ACIP) of the U.S. Department of Health and Human Services.
Covered Services
ND Medicaid members through age 18 are eligible to receive all immunization available from the federal Vaccine for Children (VFC) Program, at VFC-enrolled provider offices. Therefore, ND Medicaid will not reimburse ND Medicaid enrolled providers for a vaccine that is not supplied through the VFC program.
- Refer to ND Department of Health for the most recent Vaccine Coverage Table and Influenza Dosage Chart. This information is published by the ND Department of Health and is updated yearly.
ND Medicaid members ages 19 and over are eligible to receive annual influenza vaccine and other vaccines as indicated in Table A below per the Advisory Committee on Immunization (ACIP).
Covered Vaccine Administration
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
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)
90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)
Covered Vaccines/ Toxoids (Table A)
|
CPT Code |
Description |
Valid Ages |
Maximum Allowable Reimbursement |
VFC / 317 |
|
90619 |
Meningococcal conjugate vaccine, serogroups A,C,W,Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use. MenQuadfi™ |
2-18 yrs |
$0.00 |
√ |
|
19+ yrs |
Per Fee Schedule |
|
||
|
90620
|
Meningococcal recombinant Bexsero®
|
10-18 yrs |
$0.00 |
√ |
|
19-26 yrs |
Per Fee schedule |
|
||
|
90621 |
Meningococcal B Trumenba®
|
10-18 yrs |
$0.00 |
√ |
|
19-26 yrs |
Per Fee schedule |
|
||
|
90630 |
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative-free, for intradermal use Fluzone |
19+ |
No longer available
|
|
|
90632
|
Hepatitis A, adult dosage Vaqta® Havrix® |
19 + yrs |
Per Fee Schedule |
|
|
90633
|
Hepatitis A, pediatric /adolescent - 2 dose Vaqta® Havrix®
|
1-18 yrs |
$0.00 |
√ |
|
90636 |
Hepatitis A and Hepatitis B, adult dose Twinrix®
|
19+ yrs |
Per Fee schedule |
|
|
90647 |
Hib - 3 dose PedvaxHIB®
|
6 wks – 4 yrs |
$0.00 |
√ |
|
90648 |
Hib - 4 dose ActHIB® Hiberix®
|
6 wks – 4 yrs |
$0.00 |
√ |
|
90651 |
HPV types 6,11,16,18,31,22,45,52,58 nonvalent 3 dose Gardasil 9®
|
9-18 yrs |
$0.00 |
√ |
|
19-45 yrs |
Per Fee Schedule |
|
||
|
90653 |
Influenza vaccine, inactivated (iiv), subunit, adjuvanted Fluad®
|
65 + yrs |
Per Fee Schedule |
|
|
90654 |
Influenza virus vaccine, trivalent, split virus, preservative free, intradermal
|
19 +yrs |
Not Available |
|
|
90656 |
Influenza virus vaccine, trivalent, split virus, preservative free, 0.5 mL Afluria ® Fluvirin® |
3-18 yrs |
Not covered |
|
|
19 + yrs |
No longer available
|
|||
|
90658 |
Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for IM use Afluria® |
4 -18 yrs |
Not covered |
|
|
19 + yrs |
No longer available |
|||
|
90662 |
Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for IM use Fluzone High-Dose®
|
65 + yrs |
Per Fee Schedule |
|
|
90670 |
Pneumococcal conjugate vaccine, 13 valent (PCV13), for IM use Prevnar13®
|
6 wks - 4 yrs |
$0.00 |
√ |
|
19+ |
Per Fee Schedule |
|
||
|
90671 |
Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use Vaxneuvance™ |
19+ |
Per Fee Schedule |
|
|
90672 |
Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use FluMIst Quadrivalent® |
2-18 yrs |
$0.00 |
√ |
|
19-49 yrs |
Per Fee Schedule
|
|
||
|
90673 |
Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for IM use Flublok®
|
19 + yrs |
No longer available |
|
|
90674 |
Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for IM use Flucelvax Quadrivalent®
|
4 years-18 yrs |
$0.00 |
√ |
|
19 + yrs |
Per Fee Schedule |
|
||
|
90677 |
Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use Prevnar 20™ |
19+ yrs |
Per Fee Schedule |
|
|
90680 |
Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use Rota Teq®
|
6 wks – 8 mos |
$0.00 |
√
|
|
90681 |
Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use Rotarix®
|
6 wks – 8 mos |
$0.00 |
√ |
|
90682 |
Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin protein only, preservative and antibiotic free, for IM use. Flublok® |
19 + |
Per Fee Schedule |
|
|
90685 |
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for IM use Afluira Quadrivalent®
|
6 mos – 35 mos |
$0.00 |
√ |
|
90686 |
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for IM use Fluarix Quadrivalent® Afluria Quadrivalent® Fluzone Quadrivalent® Flulaval®
|
6 mos- 18 yrs |
$0.00 |
√ |
|
19 + yrs |
Per fee schedule |
|
||
|
90687 |
Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL, for IM use Fluzone Quadrivalent® Afluria Quadrivalent® |
6 mos – 35 mos |
$0.00 |
√ |
|
90688 |
Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for IM use Afluira Quadrivalent® Fluzone Quadrivalent®
|
6 mos – 18 yrs |
$0.00 |
√ |
|
19 + yrs |
Per Fee Schedule |
|
||
|
90694 |
Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5mL dosage for IM use Fluad Quadrivalent |
65+ years |
Per Fee Schedule |
|
|
90696 |
Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine, (DTaP-IPV) Kinrix™Quadracel™
|
4-6 yrs |
$0.00 |
√ |
|
90697 |
Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use. Vaxelis™ |
6wks-4 yrs |
$0.00 |
√ |
|
90698 |
Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine, (DTaP-IPV / Hib) Pentacel® |
6 wks – 4 yrs
|
$0.00 |
√ |
|
90700 |
Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than seven years, for IM use Daptacel® Infarix®
|
6 wks – 6 yrs |
$0.00 |
√ |
|
90702 |
Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger than 7 years, for IM use
|
6 wks – 6 yrs |
$0.00 |
√ |
|
90707 |
Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use M-M-R-II® Priorix® |
12 mos - 18 yrs |
$0.00 |
√ |
|
19+ yrs |
Per Fee Schedule |
|
||
|
90710 |
Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use ProQuad®
|
12 mos – 12 yrs |
$0.00 |
√
|
|
90713 |
Poliovirus vaccine, inactivated, (IPV), for subcutaneous or IM use IPOL®
|
6 wks – 18 years |
$0.00 |
√ |
|
19+ |
Per Fee Schedule |
|
||
|
90714 |
Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for IM use Tetanus-Diphtheria Toxoids®
|
7 years – 18 yrs |
$0.00 |
√ |
|
19 + |
Per Fee Schedule |
|
||
|
90716 |
Varicella virus vaccine (VAR), live, for subcutaneous use Varivax® |
12 mos – 18 yrs |
$0.00 |
√ |
|
19+ |
Per Fee Schedule |
|
||
|
90715 |
Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for IM use Boostrix® Adacel®
|
7-18 yrs |
$0.00 |
√ |
|
19+ yrs |
Per Fee Schedule |
|
||
|
90723 |
Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine,- (DTaP-HepB-IPV) for IM use Pediarix® |
6 wks – 6 yrs |
$0.00 |
√
|
|
90732 |
Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or IM use Pneumovax 23®
|
2-18 yrs |
$0.00 |
√ |
|
19+ |
Per Fee Schedule |
|||
|
90734 |
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MCV4 or MenACWY), for IM use Menactra® Menveo®
|
2 mos – 18 yrs |
$0.00 |
√ |
|
19 – 55 yrs |
Per Fee Schedule |
|
||
|
90736 |
Zoster (shingles) vaccine (HZV), live, for subcutaneous injection Zostavax®
|
60+ yrs |
Per Fee Schedule |
|
|
90739 |
Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for IM use Heplisav-B™
|
19+ |
Per Fee Schedule |
|
|
90740 |
Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3-dose schedule, for IM use Recombivax HB®
|
19+ yrs |
Per Fee Schedule |
|
|
90743 |
Hepatitis B vaccine (HepB), adolescent, 2-dose schedule, for IM use Recombivax HB®
|
11-15 yrs |
$0.00 |
√ |
|
90744 |
Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3-dose schedule, for IM use Enberix-B® Recombivax HB®
|
Birth -18 yrs |
$0.00 |
√ |
|
90746 |
Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for IM use Engerix-B® Recombivax HB®
|
19+ yrs |
Per Fee Schedule |
|
|
90747 |
Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4-dose schedule, for IM use Engerix-B® |
19+ yrs |
Per Fee Schedule |
|
|
90749 |
Unlisted vaccine/toxoid |
0 + |
By report
|
|
|
90750 |
Zoster (Shingles) vaccine (hzv), recombinant, sub-unit, adjuvanted, for IM use SHINGRIX®
|
50+yrs |
Per Fee Schedule |
|
|
90756 |
Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage, for intramuscular use Flucelvax® |
4 years – 18 years |
$0.00 |
√ |
|
19+ years |
Per Fee Schedule |
|
Modifier
SL - State Supplied Vaccine to be used to indicate vaccine supplied through the VFC program.
Non-Covered Services
- The cost of vaccine that is available through the VFC or 317 Program.
- Immunizations and the administration of vaccine for the sole purpose of international travel
Non-Covered Vaccine / Toxoid
|
CPT Code |
Description |
|
90477 |
Adenovirus vaccine, type 7, live, for oral use |
|
90581 |
Anthrax vaccine, for subcutaneous or intramuscular use |
|
80584 |
Dengue vaccine, quadrivalent, live, 2 dose schedule, for subcutaneous use |
|
90585 |
Bacillus Calmette-Guerin vaccine (bcg) for tuberculosis, live, for percutaneous use |
|
90587 |
Dengue vaccine, quadrivalent, live, 3 dose schedule, for subcutaneous use |
|
90625 |
Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use Vaxchora® |
|
90626 |
Tick-borne encephalitis virus vaccine, inactivated; 0.25 ml dosage, for intramuscular use |
|
90627 |
Tick-borne encephalitis virus vaccine, inactivated; 0.5 ml dosage, for intramuscular use |
|
90634 |
Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for intramuscular use |
|
90655 |
Influenza virus vaccine, trivalent (iiv3), split virus, preservative free, 0.25 ml dosage, for intramuscular use |
|
90664 |
Influenza virus vaccine, live (laiv), pandemic formulation, for intranasal use |
|
90666 |
Influenza virus vaccine, pandemic for intranasal use |
|
90667 |
Influenza virus vaccine (iiv), pandemic formulation, split virus, adjuvanted, for intramuscular use |
|
90668 |
Influenza virus vaccine (iiv), pandemic formulation, split virus, for intramuscular use |
|
90690 |
Typhoid vaccine, live, oral Vivotif® |
|
90691 |
Typhoid vaccine, vi capsular polysaccharide (vicps), for intramuscular use Typhim Vi® |
|
90694 |
Influenza vaccine, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5mL dosage, for intramuscular use |
|
90717 |
Yellow fever vaccine, live, for subcutaneous use Stamaril® |
|
90738 |
Japanese encephalitis virus vaccine, inactivated, for intramuscular use Ixiaro® |
|
90758 |
Zaire ebolavirus vaccine, live, for intramuscular use |
Billing Instructions by Claim Type
For professional services billed on a CMS 1500 / 837 P claim form, bill the Vaccine / Toxoid CPT Code along with its correlating administration code (90471-90474).
RHCs / FQHCs / Outpatient Hospital - Vaccine / Toxoid CPT Codes must be billed using Revenue Code 0636 following the coverage guidelines in Table A. The administration must be billed using Revenue Code 0771 with the appropriate CPT code. Both the vaccine and administration must be billed on the same claim.
IHS / Tribally Operating 638 Facilities - Administration must be billed using Revenue Code 0500 with the appropriate CPT code.
Created: March 2017
Updated: September 2018, August 2019; November 2019; January 2020, August 2020, June 2021, February 2022, September 2022