Immunization Administration Billed with Other Services

The guidelines described below apply to claims processed under the new claims processing system. The guidelines should be used for filing all private business claims.

The code edit changes described in the guidelines below will not override HMSA's existing medical policies.

Immunization administration codes

Billed with E/M codes

Initial immunization administration codes billed with other initial immunization administration codes

Initial immunization administration codes should not be billed with other initial immunization administration codes when services are rendered to the same patient on the same date of service. CPT descriptors use the phrases "first injection," "first administration," and "one vaccine" to describe the initial administration of a vaccine. HMSA considers that only one administration may be considered the first or initial administration, without regard to the age of the patient, counseling or means of administration.

In the following combinations of codes for initial administration of vaccines, only one code will be paid. A second initial administration code billed by the same provider for the same patient on the same date of service will not be paid.

Billed with COVID-19 codes

For commercial members, as of 09/12/2023, COVID-19 vaccines will be commercially available and covered by HMSA. 
 

The original monovalent vaccines’ emergency use authorization (EUA) has been rescinded and those vaccines are no longer recommended for use, effective November 1, 2023, see COVID-19 vaccine & vaccine administration table.   
 

IMPORTANT NOTE:  

During the public health emergency (PHE) period, COVID-19 vaccine administration payments will go out to the provider.  To avoid payment delays, we encourage that you bill COVID-19 vaccine administration separately from other services. Fully insured HMSA member’s cost-sharing (copayment, coinsurance, or deductible) shall be waived. According to Noridian, UB claims billed for COVID-19 vaccine administration shall be billed with revenue code 0771 (Preventive Care Services-Vaccine Administration).  Using other revenue codes may result to bundling into a case rate.

In addition the following code combinations will be processed as follows:

Modifiers

When billing for immunization administration with Evaluation & Management (E/M) services, it is important to bill accurately.

When the immunization administration code is billed with an E/M visit, a modifier code must be appended to the E/M code to ensure that both services are paid when appropriate. Modifier 25 would generally be used for this purpose, if criteria for the use of this modifier are met.

In other cases, modifier code 59 may be needed to distinguish one immunization administration from another.

Please review the criteria for the use of modifiers 25 and 59.

Modifier Code 25

Modifier Code 59

The use of modifier 25 stipulates that the E/M service performed was a significant, separately identifiable service above and beyond the other service provided. HMSA recognizes that there is some degree of E/M performed in a physician's office when an immunization is administered. But this would not be considered significant when the patient's sole purpose for the visit is to receive the immunization. An example might be an older adult, basically in good health, who goes to his or her physician for an annual flu shot. No other services are rendered. In this case, only the immunization should be billed.

Modifier codes should only be used when the service meets the criteria described in CPT and HMSA's policies. HMSA will perform postpayment reviews of modifier usage as needed to verify modifiers were used as described. If postpayment review indicates that modifiers were not used appropriately, HMSA will request return of any overpayment. See Benefit Overpayment.