Pediatric Vaccine Counseling Now Covered for Medicaid and Personal Wellness Plan (HARP) Members

Counseling Conditions

Childhood vaccine counseling may be provided: 

• As a stand-alone service when all the criteria specified in this guidance are met and documented. 
• In addition to an Evaluation and Management (E&M)/Well-Child Visit when all the criteria of the vaccine counseling visit specified in this guidance are met and documented. 
• In addition to all necessary components of the E&M/Well-Child visit; whether or not a recommended vaccine is administered, or vaccine administration is billed for, during the encounter. 
• For up to six counseling visits per NYS Medicaid member, per year, for NYS members zero years of age through 18 years of age, when they have not received the Advisory Committee on Immunization Practices (ACIP) recommended doses and do not have an appointment to receive the recommended dose.

Counseling Documentation Requirements

All childhood vaccine counseling sessions must be documented in the medical or pharmacy* record and must include the elements detailed below:

✓  Confirmation from the parent, guardian, caregiver, or patient (if appropriate) that the patient is not currently “up to date” with childhood vaccination doses.

✓  Confirmation of vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible.

✓  Confirmation that the patient does not have an appointment scheduled to receive the vaccine dose for which they are being counseled.

✓  Reason(s) expressed by the parent or caregiver for vaccine hesitancy.

✓  Recommendation of the vaccine(s).

✓  Counseling the parent, guardian, caregiver, or patient (if appropriate), on the safety and effectiveness of the vaccine(s).

✓  Answer any questions that the parent, guardian, caregiver, or patient (if appropriate) have regarding the recommended vaccine(s).

✓  Counseling the parent, guardian, caregiver, or patient (if appropriate) for a minimum of eight minutes.

✓  Arrangement for vaccination(s) or providing information to the parent, guardian, caregiver, or patient (if appropriate) on how the patient can get vaccinated.

*Through December 31, 2024, childhood vaccine counseling may be provided by a pharmacy in accordance with the Public Ready and Emergency Preparedness (PREP) Act.

Counseling Billing Guidance

To be reimbursed for Childhood Vaccine Counseling, providers submitting professional claims are to bill with the Current Procedure Terminology (CPT) code detailed in the grid below:

Additional Resources

New York State Medicaid Update - August 2024 Volume 40 - Number 8 (ny.gov)

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am–5:30pm.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”).
R24-95
Released December 2024