R 418.10902a Billing for vaccines and toxoids in office setting.

Rule 902a. (1) When a provider administers a vaccine or toxoid in the office setting, both the vaccine and toxoid shall be billed as separate services. If a significantly separate evaluation and management service is performed, the appropriate evaluation and management service code shall be reported in addition to the vaccine or toxoid administration code pursuant to CPT codebook guidelines, as adopted by reference in R 418.10107. (2) The vaccine or toxoid being administered and the administration of the vaccine or toxoid shall be billed using the applicable CPT procedure codes pursuant to CPT codebook guidelines, as adopted by reference in R 418.10107. (3) The provider shall list the NDC number for the vaccine or toxoid in the upper shaded portion of box 24 of the CMS 1500. (4) The carrier shall reimburse the vaccine or toxoid at the average wholesale price (AWP) minus 10%, as determined by Red Book or Medi-Span, as adopted by reference in R 418.10107. No dispensing fee shall be billed for vaccines or toxoids administered in the office setting. (5) If the provider does not list the NDC number for the vaccine or toxoid, the carrier shall reimburse the vaccine or toxoid using the least costly NDC number listed by Red Book or Medi- Span for that vaccine or toxoid.