The North Carolina Medicaid program officially covers Shingrix, the recombinant zoster vaccine, since November 8, 2017, under its Physician’s Drug Program (PDP). This coverage ensures that eligible adults can receive this crucial vaccine to prevent herpes zoster, commonly known as shingles. For healthcare providers navigating the billing process, understanding the correct diagnosis and procedure codes is essential for seamless reimbursement. This guide provides a detailed overview, focusing on the Diagnosis Code For Shingrix, alongside other vital billing information to ensure accurate claim submissions.
Shingrix is administered as a two-dose series to adults aged 50 years and older for the prevention of shingles. It’s important to note that Shingrix is specifically for shingles prevention and not for primary varicella infection (chickenpox). Each dose is 0.5 mL, given intramuscularly, with the second dose recommended two to six months after the first.
Understanding the Essential Diagnosis Code for Shingrix Billing
When billing Medicaid for Shingrix administration, a specific ICD-10-CM diagnosis code is mandatory. The designated diagnosis code for Shingrix immunization encounters is Z23 – Encounter for immunization. This code accurately reflects the purpose of the patient visit – to receive a preventive vaccine. Using the correct diagnosis code is the foundational step in ensuring your claims are processed without delays.
CPT Code and Billing Specifications for Shingrix
Alongside the diagnosis code, the Current Procedural Terminology (CPT) code for Shingrix administration is equally critical. Providers must use CPT code 90750, which is defined as: “Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection.”
Key billing specifications to keep in mind include:
- Unit of Coverage: One Medicaid unit of coverage is 0.5 mL, representing a single dose of Shingrix.
- Maximum Reimbursement Rate: The maximum reimbursement rate per unit is set at $144.20.
- National Drug Codes (NDCs): Accurate billing requires the 11-digit NDCs. For Shingrix, these are 58160-0823-11 and 58160-0819-12.
- NDC Units: Report NDC units as “UN1.”
For comprehensive details on NDC implementation, providers can refer to the January 2012 Special Bulletin, National Drug Code Implementation Update. Further information on NDC claim requirements within the PDP is available in the Clinical Coverage Policy No. 1B, Physician Drug Program, specifically Attachment A, H.7 on the Medicaid website.
Billing for 340-B and Non-340-B Drugs
An important distinction in Medicaid billing is between 340-B and non-340-B drugs. For non-340-B drugs, providers should bill their usual and customary charges. However, for providers participating in the 340-B program and billing for drugs acquired under a 340-B purchasing agreement, it’s crucial to bill at their acquisition cost. To indicate that a drug was purchased under a 340-B agreement, append the “UD” modifier to the drug detail. Eligibility for 340-B program participation requires registration with the Office of Pharmacy Affairs (OPA).
The complete fee schedule for the PDP is accessible on the North Carolina Medicaid PDP web page, offering an additional resource for accurate billing and reimbursement information.
For any further assistance or clarification, providers are encouraged to contact CSRA directly at 1-800-688-6696. Ensuring correct usage of the diagnosis code for Shingrix (Z23) and adherence to all billing guidelines will facilitate timely and accurate reimbursement for this essential preventive service.
