Coding Guidelines for Vaccine-Preventable Hepatitis (VPH)
High-risk populations, including men who have sex with men.
Many insurers offer coverage for fprotection against vaccine-preventable hepatitis (VPH) - Hepatitis A and Hepatitis B - for high-risk populations, including men who have sex with men (MSM). Coverage and actual dollar reimbursements often vary among insurers, as well as on the patient's individual insurance plan. The actual reimbursement may also depend on whether or not the patient has met his or her annual deductible and/or co-pay requirements. Below are some guidelines for seeking reimbursement for immunization against VPH for high-risk patients. For answers to reimbursement questions on a patient-by-patient basis, contact the VACCRIX Reimbursement Hotline at 888-VACCRIX (888-822-2749). (Service underwritten by GlaxoSmithKline; information given regardless of the vaccine used.)*
Note: Medicaid and some state-administered programs for underserved patients may also cover protection against VPH for high-risk patients. Check with your individual state offices to determine the eligibility requirements and reimbursement policies in your area.
Appropriate coding for immunization against VPH
Appropriate CPT® and ICD-9 codes are required for each claim submission for the performance of an immunization against VPH. Even if immunization against VPH (along with other vaccinations) is considered a routine service by the insurer, appropriate coding will be required for payment.
There are separate CPT codes for the vaccine product, for the administration of the vaccine and for patient evaluation and management services. AMA members may call 800-634- 6922 for CPT coding advice.
A number of ICD-9 diagnosis codes can be used to identify the VPH high-risk population. To protect the patient's confidentiality, you may wish to discuss using a code that indicates a specific risk factor/group with the patient prior to contacting the insurer. Example with an HIV-positive patient: Most insurers cover immunization against VPH in an HIV positive patient because of the high risks and costs associated with VPH in these patients. To bill, use the ICD-9 diagnosis code to identify HIV (ICD-9 code 042) along with the appropriate CPT code (90747 for hepatitis B vaccine for immunosuppressed patient or 90632 for hepatitis A vaccine) plus the appropriate CPT administration code (90471 for immunization administration).
Example with an HIV-negative patient exposed to viral hepatitis: Insurers will consider payment for hepatitis A and B vaccines if a patient is exposed to hepatitis A or B but does not show signs of disease. To bill, use the ICD-9 diagnosis code for contact with or exposure to communicable disease, other viral diseases (ICD-9 code V01.7) along with the appropriate CPT code (90746 for hepatitis B vaccine or 90632 for hepatitis A vaccine) plus the appropriate CPT administration code (90471 for immunization administration).
If denied by the insurer
Contact the insurance company and request a review of the initial claim submission. Be sure to identify the appropriate high-risk population for your patient. An effective claim appeals letter will need to be developed if the telephone call to reverse the claim denial is unsuccessful. Request a pre-treatment benefit verification before the immunization against VPH is to be incurred by a patient to reduce the number of instances when the insurance company will not cover the service. Once a claim is received and denied, it may take more effort to receive payment from the insurance company.
Note: None of the above information is a guarantee of coverage. All claims are subject to individual plan coverage, guidelines and the submission of the actual claim. There are also many variables that determine claim payment. Coverage and reimbursement amounts are specific according to the individual plan that a member or their employee has purchased, as well as the negotiated contract for each provider. Blanket statements regarding coverage may not be accurate and this information is intended as a guideline only.
Persons in these groups are at risk for Hepatitis A virus or B virus infection and should be vaccinated:
Hepatitis A high-risk groups
- Men who have sex with men.
- People with chronic liver disease, including people with hepatitis B and hepatitis C
- Illicit drug users
- People with clotting-factor disorders
- Children living in areas with historically high rates of hepatitis A infections (see www.cdc.gov/ncidod/diseases/ hepatitis/slideset/hep_a/slide_40.htm)
- People who work with hepatitis A virus in experimental lab settings (not routine medical laboratories)
- People who travel outside of the U.S. (except for Western Europe, New Zealand, Australia, Canada and Japan)
- Food handlers when health authorities or private employers determine vaccination to be cost effective
Hepatitis B high-risk groups
- Men who have sex with men
- Household contacts and sex partners of HBsAg-positive persons
- Users of illicit injectable drugs
- Heterosexuals with more than one sex partner in six months
- People with recently diagnosed STDs
- Patients receiving hemodialysis and patients with renal disease that may result in dialysis
- Recipients of certain blood products
- Health care and public safety workers who are exposed to blood
- Clients and staff of institutions for the developmentally disabled
- Inmates of long-term correctional facilities
- Certain international travelers
- Immigrants/refugees from areas with high endemic rates of Hepatitis B infection (Asia, Pacific Islands, Sub-Saharean Africa, Amazon Basin, Eastern Europe, Middle East)
- Asian and Pacific islanders (pre-vaccination screening may be appropriate)
- Adopted children from countries where Hepatitis B is endemic (see above list)
- All adolescents
Centers for Disease Control and Prevention Hepatitis Home Page
American College of Gastroenterology: Chronic Liver Disease: A Primer on Vaccinations
American Academy of Family Physicians: Preventive Strategies in Chronic Liver Disease
National Institute of Health Consensus Statement - Management of Hepatitis C: 2002
American Medical Association CPT Home Page
These guidelines were produced by the American Medical Association (AMA) to complement the Centers for Disease Control and Prevention outreach program to combat VPH in high-risk populations, such as men who have sex with men. Please visit the AMA Web site at www.amaassn.org/go/infectious to download these materials.
Current Procedural Terminology (CPT©) is copyright 2003 American Medical Association. All Rights Reserved. This pamphlet contains selected codes for Hepatitis B vaccine procedures. For complete coding and guidelines, please always refer to AMA's Current Procedural Terminology (CPT©). CPT is a registered trademark of the American Medical Association
* The use in this brochure of any company name or mention of any company product or service is for identification purposes only and does not imply endorsement by the American Medical Assocation.