This guide clarifies the essential diagnosis and billing codes for healthcare providers administering the Hepatitis B vaccine (Heplisav-B) to adult patients, particularly focusing on requirements for programs like North Carolina Medicaid and NC Health Choice (NCHC), though relevant for broader understanding. Accurate coding ensures proper reimbursement and efficient processing of claims for this vital preventative service.
Key Diagnosis Code: Z23 – Encounter for Immunization
For all billings related to the Hepatitis B vaccine, the primary and required ICD-10-CM diagnosis code is Z23 – Encounter for immunization. This code clearly indicates that the patient encounter’s primary purpose was to receive a vaccination. Using this precise diagnosis code is crucial for claim acceptance and accurate record-keeping.
HCPCS Code for Heplisav-B: 90739
When billing for Heplisav-B, the adjuvanted Hepatitis B vaccine for adults, you must use the Healthcare Common Procedure Coding System (HCPCS) code 90739 – Hepatitis B vaccine (HepB), adult dosage, two dose schedule, for intramuscular use. This code is specific to the adult dosage and two-dose schedule of Heplisav-B, administered intramuscularly. It distinguishes this vaccine from other Hepatitis B vaccine formulations or schedules.
National Drug Codes (NDCs) and Billing Units
For claim submissions, particularly within Medicaid and NCHC, it’s necessary to include the National Drug Code (NDC) for Heplisav-B. The NDCs are:
- 43528-0002-01
- 43528-0002-05
Report these 11-digit NDCs on your claims along with the appropriate units. One Medicaid unit is equivalent to 0.5 mL, which is the single dose vial size of Heplisav-B. Therefore, when billing, ensure to use “UN1” as the NDC unit.
Reimbursement Details
The maximum reimbursement rate per 0.5 mL Medicaid unit for Heplisav-B is $118.45. This rate is subject to change, so always refer to the latest Medicaid fee schedules for the most current information. Providers should bill their usual and customary charges for non-340-B drugs.
Billing for 340-B Purchased Drugs
For providers participating in the 340-B drug pricing program and purchasing Heplisav-B under this agreement, it is essential to bill the acquisition cost. To correctly identify these claims, append the “UD” modifier to the drug detail when billing for 340-B purchased vaccines. This ensures compliance and accurate reimbursement within the 340-B program framework.
Further Information and Resources
For comprehensive details regarding NDC claim requirements, refer to the January 2012 Special Bulletin on National Drug Code Implementation Update. Additional information about PDP claim requirements can be found in the PDP Clinical Coverage Policy No. 1B, Attachment A, H.7 on the North Carolina Medicaid website. The Physician Administered Drug Program (PDP) fee schedule is also available on the Medicaid PDP web page. For any billing inquiries, contact CSRA at 1-800-688-6696.
By adhering to these coding and billing guidelines, healthcare providers can ensure accurate claim processing and reimbursement for the administration of the Hepatitis B vaccine (Heplisav-B), facilitating continued access to this crucial preventative healthcare service for adult patients.
