Provider reimbursement for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Counseling program

This notice is a clarification of the appropriate coding for provider reimbursement for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program when provided to Medicaid members ages 18 years of age or younger. Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)

 

	CPT® code	Fee	Notes
Claims based	CPT 99401 DX: Z71.85	$12.50	A provider submitting professional claims should bill Current Procedure Terminology (CPT) code 99401 for preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required and recommended for ages 18 years or younger.

 

Key details — The childhood vaccine counseling session must be documented in the medical or pharmacy record and must include the following:

• CPT 99402: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure).
• Providers should bill CPT 99402 with ICD-10 code Z71.85.
• Confirm vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible.
• Providers are encouraged to counsel all members who have not already have an appointment scheduled to receive the vaccine dose for which they are being counseled.
• For more information, visit https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

 

NYBCBS-CAID-001698-22 June 2022