Updated: August 11, 2022

In accordance with the correct coding initiative as well as the associated changes to the TMPPM, specifically section 5.3.11.3 Immunizations, the sequence of billing codes for administration of immunizations needs to be changed. Claims that are not billed in the proper sequence will be denied by Community First.

Community First will deny claims that are not submitted in the correct sequence. This is based on guidance from TMHP, and the proper sequence can be found in the TMPPM, specifically section 5.3.11.3 Immunizations. Providers will need to adjust their billing practices for immunization administration for Community First to process the claims appropriately. Claims that are not submitted with the correct sequence will be denied by Community First.

Providers will need to adjust their billing practices to submit vaccination claims in the correct sequence to avoid denial of claims. This system goes into effect February 1, 2022.

Providers must submit claims for immunization procedure codes 90460 or 90461 based on the number of components per vaccine. Providers must specify the number of components per vaccine by billing 90460 and 90461 as defined by the procedure code descriptions:

  • Procedure Code 90460 is submitted for the administration of the 1st component
  • Procedure Code 90461 is submitted for the administration of each additional component identified in the vaccine.

Procedure code 90461 will be denied if procedure code 90460 has not been submitted on the same claim for the same vaccine or toxoid.

The necessary counseling that is conducted by a physician or other qualified healthcare professional must be documented in the client’s medical record.

The following is an example of how to submit claims for immunization administration procedure codes when counseling is provided:

Procedure codes 90471, 90472, 90473, and 90474 may be reimbursed per vaccine based on the route of administration.

The following is an example of how to submit claims for injection administration procedure codes when counseling is not provided:

Resources:
TMPPM section 5.3.11.3 Immunizations

Contact:
For any questions, please call 210-358-6294 or email ProviderRelations@CFHP.com

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