This guide clarifies the essential diagnosis and procedure codes for healthcare providers in North Carolina seeking to bill Medicaid for the Shingrix vaccine. Accurate coding ensures proper reimbursement for this crucial preventative service against shingles in adults aged 50 and over.
Shingrix Vaccine: Coverage and Indication
Effective November 8, 2017, North Carolina Medicaid covers Shingrix (zoster vaccine recombinant, adjuvanted) under the Physician’s Drug Program (PDP). Shingrix is a recombinant, subunit, adjuvanted vaccine administered intramuscularly to prevent herpes zoster (shingles). It is specifically indicated for adults aged 50 years and older and is not for the prevention of chickenpox (primary varicella infection).
The recommended immunization schedule for Shingrix involves two doses (0.5 mL each). The initial dose is administered at month zero, followed by a second dose between two and six months later. Each dose is prepared by reconstituting a single-dose vial of lyophilized varicella zoster virus glycoprotein E (gE) antigen component with the accompanying AS01B adjuvant suspension.
Medicaid Billing Codes for Shingrix
To ensure successful Medicaid billing for Shingrix, providers must use the correct diagnosis and procedure codes. Here’s a breakdown of the necessary codes and billing guidelines:
Primary Diagnosis Code: Z23 – Encounter for Immunization
The ICD-10-CM diagnosis code mandated for Shingrix vaccine billing is Z23 – Encounter for immunization. This code clearly indicates that the encounter’s primary purpose was for vaccination. Using Z23 ensures that the claim is correctly processed as a preventative service.
Procedure Code: 90750 – Zoster Vaccine, Recombinant, Adjuvanted
The CPT code required for billing Shingrix is 90750 – Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection. This code precisely identifies the administered vaccine, specifying it as the recombinant, adjuvanted shingles vaccine (Shingrix).
Units of Coverage and Reimbursement
For Medicaid billing purposes:
- One Medicaid unit of coverage is defined as 0.5 mL, which is the standard single dose of Shingrix after reconstitution.
- The maximum reimbursement rate per 0.5 mL unit is $144.20. Providers will be reimbursed up to this rate.
National Drug Codes (NDCs)
Providers are required to include 11-digit National Drug Codes (NDCs) on their claims. The specific NDCs for Shingrix are:
- 58160-0823-11
- 58160-0819-12
When submitting claims, the NDC units should be reported as “UN1” to indicate one unit.
340-B Drug Program Billing
For providers participating in the 340-B Drug Pricing Program:
- If billing for non-340-B drugs, providers should bill their usual and customary charge.
- For 340-B purchased drugs, reimbursement is based on the provider’s acquisition cost. To indicate that Shingrix was purchased under a 340-B agreement, append the “UD” modifier to the drug detail on the claim.
- Participating providers must be registered with the Office of Pharmacy Affairs (OPA).
Additional Resources
For more detailed information, providers can refer to the following resources:
- January 2012, Special Bulletin, National Drug Code Implementation Update: National Drug Code Implementation Update
- Clinical Coverage Policy No. 1B, Physician Drug Program, Attachment A, H.7: Physician Drug Program on the Medicaid website.
- PDP Fee Schedule: Available on the North Carolina Medicaid PDP web page.
For any billing inquiries or further assistance, providers can contact CSRA at 1-800-688-6696.
By adhering to these guidelines and utilizing the correct diagnosis and procedure codes, healthcare providers can ensure accurate and efficient billing for the Shingrix vaccine under North Carolina Medicaid, facilitating access to this important preventative measure for eligible adults.
