SJHAP IMMUNIZATION BILLING GUIDELINES

yAll immunizations are subject to health plan criteria and member benefit coverage.
yOffices are encouraged to purchase through SJHAP's Med Assets program.
yMembers may not be charged for an immunization unless the immunization is not a covered benefit.
yTo receive payment for administration fees, claims must include the appropriate CPT code(s) for both the
administration and immunization rendered.
SJHH reimbursement and guidelines for immunizations are subject to the provisions of SJHH Health Plan
Agreements.
COMMERCIAL HMO MEMBERS
Admin Fee
Health Plan Bill to: Immunization Billing Instructions
Aetna SJHAP Bill ALL immunizations to Aetna
Blue Cross SJHAP Bill ALL immunizations to Blue Cross
Blue Shield SJHAP Bill ALL immunizations to SJHAP
Bill ALL immunizations to SJHAP
HPV vaccine for males is based on the recommendation of the health care
Health Net SJHAP professional.
Bill SJHAP for ALL immunizations except the following:
Bill to Cigna: 90649 (HPV both male & females), 90680 / 90681 (rotavirus),
Cigna SJHAP 90736 (zoster), 90716 (varicella 2nd dose)
Bill SJHAP for ALL immunizations except the following:
Pacificare and SJHAP are not covering the HPV vaccine for males
Bill to Pacificare: 90649 (females only) / 90650 (HPV), 90670 (PCV13),
Pacificare (Under 18) SJHAP 90680 / 90681 (rotavirus), 90716 (varicella 2nd dose)
Bill ALL immunizations to SJHAP ( except HPV for males)
Pacificare (Over 18) SJHAP Pacificare and SJHAP are not covering the HPV vaccine for males

MEDICARE ADVANTAGE PLAN MEMBERS

Admin Fee
Health Plan Bill to: Immunization Billing Instructions
Aetna SJHAP Bill ALL immunizations to SJHAP*
Blue Shield SJHAP Bill ALL immunizations to SJHAP*
Health Net SJHAP Bill ALL immunizations to SJHAP*
Secure Horizons SJHAP Bill ALL immunizations to SJHAP*
SCAN SJHAP Bill ALL immunizations to SJHAP*
*NOTE: 90736 (zoster) and the applicable admin fee is covered under the member's Part D benefit. Please contact
the health plan for information.

Rev 9/15/10
 St. Joseph Hospital Affiliated Physicians
Immunization & Injectable Reimbursement Schedule
September 15, 2010

All immunization and injections are subject to health plan criteria and member benefit coverage.
Offices are encouraged to purchase through SJHAP's Med Assets program. Reimbursement is established at
MedAssets pricing.
To receive payment for administration fees, claims must include the appropriate CPT code(s) for both the
administration and immunization rendered. Billed amount must be greater or equal to the MFS amount.

SJHH reimbursement for immunizations and injections are subject to the provisions of SJHH Health Plan
agreements. Payment will not be made if it is not the financial responsibility of SJHH.

IMMUNIZATION ADMINISTRATION
CPT Code Description Reimbursement
Immunization administration under 8 years of age (includes percutaneous, intradermal, subcutaneous,
or intramuscular injection) when the physician counsels the patient/family; one vaccine (single or
90465 combination vaccines/toxoid) MFS
each additional vaccine (single or combination vaccines/toxoid) (list separately in addition to code for
90466 primary procedure) MFS
H1N1 Immunization administration (intramuscular and intranasal) including counseling when
90470 performed 25.41
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular
90471 injection); one vaccine (single or combination vaccines/toxoid) MFS
each additional vaccine (single or combination vaccines/toxoid) (list separately in addition to code for
90472 primary procedure) . MFS
Immunization administration by intranasal or oral route; one vaccine (single or combination
90473 vaccine/toxoid). Note: Code to be used for all ages. MFS
Each additional vaccine (single or combination vaccines/toxoid) (list separately in addition to code for
90474 primary procedure) Note: Code to be used for all ages. MFS
MFS - Reimbursement is based on the current Medicare Fee Schedule.

IMMUNIZATIONS AND INJECTABLES

CPT Code Description Reimbursement
86580 Tuberculin PPD 3.28
86735 Mumps Skin Test Antigen 19.95
90586 BCG, Intravesical 104.80
90632 Hepatitis A (Adult) 62.48
90633 Hepatitis A (Pediatric) 28.46
90636 Hepatitis A and B 88.97
90647 Hib (3-dose series) 22.74
90648 Hib (4-dose series) 23.61
90649 HPV quadrivalent 130.14
90650 HPV bivalent 127.47
90655 Influenza virus vaccine, preservative free - age 6-35 mos 11.94*
90656 Influenza virus vaccine, preservative free - age 3 years and above 11.31*
90657 Influenza virus vaccine - age 6-35 mos 5.05*
90658 Influenza virus vaccine - age 3 years and above 10.10*
90660 Influenza virus vaccine, live - intranasal 18.75
90662 Influenza virus vaccine-enhanced immuogenicity-Age 65 & over 25.40
90663 Influenza virus vaccine, pandemic formulation, H1N1. SEE BELOW 0.00
90669 PCV7, Pneumococcal conjugate 83.88*
90670 PCV13, Pneumococcal conjugate 108.75

Updated 9/22/2010
 St. Joseph Hospital Affiliated Physicians
Immunization & Injectable Reimbursement Schedule
September 15, 2010

IMMUNIZATIONS AND INJECTABLES

CPT Code Description Reimbursement
90675 Rabies (HDCV) 177.12
90680 Rotavirus, pentavelent (3 dose) 69.51
90681 Rotavirus, attenuated (2 dose) 101.48
90691 Typhoid 45.82
DTap-IPV Diphtheria, tetanus toxoids and acellular pertussis vaccine, and poliovirus
90696 vaccine, inactivated 47.55
DTaP-IPV/Hib Diptheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type
90698 B, and poliovirus vaccine, inactivated 75.33*
90700 DTaP 20.77
90702 Diph/Tet (DT) 30.44
90703 Tetanus Toxoid, Adsorbed 27.04
90704 Mumps 22.22
90705 Measles 17.17
90706 Rubella 19.13
90707 Measles, Mumps & Rubella 48.27
90710 MMRV (MMR + Varicella) 124.24
90713 Polio, inactivated (IPV) 24.71
90714 Diph/Tet (Td) 19.49
90715 Tdap Tetanus Toxoid, Reduced Diphtheria Toxoid & Acellular Pertussis 37.20*
90716 Varicella 80.50
90717 Yellow Fever 64.84
90721 DTaP/Hib 46.35
90723 DTaP/Hep B/IPV 66.75
90732 PPSV23, Pneumococcal polysaccharide 32.95
90733 Meningococcal (A/C/Y/W-135) 105.41
90734 Meningococcal (A/C/Y/W-135) 103.41
90735 Japanese Encephalitis 96.30
90736 Zoster 153.78
90743 Hepatitis B (Ped/Adol)-2 dose sched 28.04*
90744 Hepatitis B (Ped/Adol)-3 dose sched 14.02*
90746 Hepatitis B (Adult) 28.04*
90748 HIB/Hepatitis B 43.51
J2790 Rh(D) Immune Globulin** 104.45
J0696 Ceftriaxone sodium, 250 mg** MFS

NOTES:
BOLD - Indicates NEWLY added immunization/injection to schedule.
* Rate change from previous Reimbursement Schedule.
** See Injectable Grid for instructions.
90663- H1N1 influenza vaccine is not payable. Vaccine purchased by the federal government and distributed to
health care providers.

Updated 9/22/2010