Monday, January 2, 2012

CPT code 90649 Human Papilloma virus (HPV) vaccine

Gardasil (Quadrivalent Human Papillomavirus [Types 6, 11, 16, 18] Recombinant Vaccine)

CPT CODE: 90649 Human Papilloma virus (HPV) vaccine, Types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use Indications for use: Indicated in males and females 9-26* years of age for the prevention of the following diseases caused by Human Papillomavirus (HPV) types 6, 11, 16, 18:

• Cervical cancer

• Genital warts (condyloma acuminata) (males and females) and the following precancerous or dysplastic lesions:

• Cervical adenocarcinoma in situ (AIS)

• Cervical intraepithelial neoplasia (CIN) grade 2 and grade 3

• Vulvar intraepithelial neoplasia (VIN) grade 2 and grade 3

• Vaginal intraepithelial neoplasia (VaIN) grade 2 and grade 3

• Cervical intraepithelial neoplasia (CIN) grade1

Billing and Claim Form

Effective October 1, 2016, all claims must be filed electronically. See blue box notification. Policy change to improve efficiency in processing claims Human papillomavirus (HPC) vaccine Replaced CPT codes 90649 and 90650 with CPT code 90651. Listed new virus types in new vaccine.

Program update Required training for screening, brief interventions, and referral to treatment (SBIRT) services

Removed the “minimum of four hours” of SBIRT training, and replaced it with “SBIRT training approved by the agency.” Also added that “this requirement is waived if a provider has an addiction specialist certification. The provider must submit proof of this certification to the agency by mail or fax.” Program update Targeted tuberculosis testing with interferongamma release assays

Added “exposure less than two years before the evaluation” Also added this to expedited prior authorization code #870001325. Program update Billing for singledose vials

Aligned wording to other areas of the billing guide. Consistency Eye examinations and refraction services

Added “supporting medical documentation must be submitted with the claim” to the section on coverage for additional examinations and refraction services. Also added “Authorization is not required for two or less replacement glasses. More than two pairs of glasses in a 12 month period requires Prior Authorization (PA).” Clarification

Mental health The reimbursement rate may differ depending on the provider’s education level. See the Mental Health Services and the Physician-Related/Professional Services fee schedules for details. Clarification

CRITERIA: - the HPV vaccine should be administered intramuscularly as 3 separate 0.5-mL doses with the first dose given at elected date, second dose given 2 months after the first dose and the third dose given 6 months after the first dose

• ND Medicaid will reimburse for the HPV vaccine and the immunization administration for date of service 1/1/10 and after, for males and females 19-21* years of age at the current rate.

• ND Medicaid will reimburse the HPV vaccine and the immunization administration for males and females 9-18 years of age** ONLY if there is a national shortage of the HPV vaccine. The NDDoH – VFC Program will notify ND Medicaid if this should occur.

* ND Medicaid will only allow/reimburse Gardasil (HPV) vaccine (non-VFC qualified) for males and females age 19 through 21 years of age. ND Medicaid will NOT allow/reimburse Gardasil for males and females 22 years of age and older.

** The claim must be submitted on a CMS 1500 (paper) and note in Box 19 stating, “National shortage of HPV vaccine.”

Uses and Restrictions for HPV Codes 90649 and 90650

The following uses and restrictions for Human Papilloma Virus (HPV) vaccines CPT code 90649 (Gardasil®) and CPT code 90650 (Cervarix®) are effective for claims dates of service on/after Oct. 21, 2009.

• CPT code 90649, formerly for females only, may be used for boys and young men age 9-26. Please note that for recipients age 9-18, code 90649 is reimbursed through the Vaccines For Children (VFC) program.

• CPT code 90650 is an FDA-approved HPV vaccine for females only age 9-26. For recipients age 9-18, code 90650 is reimbursed through the VFC program.

• The three-dose schedule for either code for recipients over age 18 must begin and end before the recipient turns 27. Medicaid cannot reimburse for any dose(s) given after the recipient turns 27, because the vaccine is not approved by the FDA for recipients over the age of 26.

• Any claims for CPT codes 90649 and 90650 submitted on/after Oct. 21, 2009, that denied inappropriately have been reprocessed and the adjudication is reported on remittance advices.


V04.89 - Need for prophylactic vaccination and inoculation against, Other viral diseases

CODING/BILLING: 90649 (Human Papilloma virus - HPV) vaccine - $127.50 (ND Medicaid
allowed amount) for each of three (3) doses for males and females 19-21* years of age. (see CRITERIA for clarification)


90649-SL (Human Papilloma virus - HPV) vaccine –SL (state supplied) - $0.00 must be submitted for males and females 9-18 years of age who qualify and receive VFC vaccine.


90471 or 90472 The appropriate immunization administration code and charge must be billed with each HPV vaccine (90649).

►Guideline CHANGE: Effective January 1, 2010 ND Medicaid will allow/reimburse Gardasil (HPV) vaccine for males and females age 19 through 21 years of age. This change now allows reimbursement of the HPV vaccine and vaccine administration to males as well as females age 19-21 years of age.

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