01/05/2024
What is New
For dates of service on or after October 1, 2023, the respiratory syncytial virus (RSV) vaccine, procedure code 90678, is now a benefit for both Texas Medicaid and Texas Health Steps. This applies to age groups who are 10 years of age or older and/ or pregnant individuals at 32 through 36 weeks gestation.
Highlights:
- Vaccine procedure code 90678 may be reimbursed for the following types and places of services:
- Office: Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Pharmacist, Certified Nurse Midwife, Registered Nurse, Licensed Midwife, Comprehensive Care Program (CCP), and Pharmacy
- Home: Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, and Comprehensive Care Program Provider
- Outpatient Hospital: Hospital Providers,
- Other Locations: Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, and Physician, Comprehensive Care Program Provider
- Texas Health Steps may be reimbursed for services rendered in the office, home, outpatient hospital, and other location settings.
- Providers may administer vaccine to eligible individuals for the Vaccine for Children (VFC) program and should come from VFC – provided stock. When vaccines are administered to individuals through 18 years of age, reimbursement will process as informational only. Providers may use modifier U1 on submitted claims, if the RSV vaccine is not available through VFC.
How does this impact me
- You do not have to resubmit claims with procedure codes 90678 with dates of service on or after October 1, 2023. Claims will be automatically reprocessed for appropriate payment. However, you will need to resubmit any claim denied for other reasons after the claims reprocessing is complete.
Questions
Providers, for questions or additional information, please:
- Contact your Medicaid Provider Network Representative at 1-855-212-1615.
- Submit via email: Texas Medicaid Network Department
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.