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
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.”
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.