Federal and state health departments usually supply influenza, pneumococcal, COVID-19, and hepatitis B vaccines for free to healthcare providers to prevent the spread of contagious diseases through various programs like VFC.
According to the U.S. Centers for Disease Control and Prevention’s ‘Vaccination Trends’ for 2024-25, nearly half of the adult population in the USA is vaccinated against infectious respiratory diseases like influenza and RSV. Free immunization drives are a contributing factor to that.
Let’s dissect modifier SL in today’s detailed guide to explore how you can still receive reimbursement for administering a vaccine product supplied by the state for free.
Modifier SL – Description
Modifier SL is appended to Current Procedural Terminology (CPT) codes for vaccine and immunization administration to indicate that the vaccine product was state-supplied and obtained at no cost to the healthcare provider.
Healthcare providers receive free vaccine products from “the Department of Health (DOH) through the Universal Vaccine Distribution program and the Federal Vaccines for Children (VFC) program for children” 18 years old or younger to prevent the outbreak and spread of contagious diseases. While they cannot charge for the state-supplied vaccine product, providers can bill government and private health insurance payers for administering the vaccine to the beneficiaries.
When to Use Modifier SL?
Even the most seasoned healthcare personnel can get confused when it comes to coding and billing state-supplied vaccines. From selecting the most appropriate vaccine product and service codes to deciding which code to append modifier SL, they struggle to make these seemingly simple decisions.
But that does not have to be the case with you. Below, we have discussed a few real-world examples where modifier SL can be used accurately for rightful reimbursement collection. Take a look!
State-Supplied COVID-19 Vaccine Drive During Pandemic
Let’s go back in time for our first example. Remember how the COVID-19 pandemic forced us all into isolation, making us fear the very thought of human-to-human contact? While the pandemic was catastrophic, its vaccine distribution was equitable and efficient.
The United States was among the first to receive COVID-19 vaccine doses from Pfizer-BioNTech and began its vaccination drive for individuals 16 years and older. The state-supplied vaccines were distributed to healthcare providers at no cost. Soon enough, people could walk into their nearest CVS and get their free COVID-19 vaccine shot. But how were healthcare providers seeking reimbursement for the vaccine administration?
Imagine that a 66-year-old Medicare beneficiary visited the outpatient unit of a panel hospital. Since he was elderly and had underlying medical conditions, he was one of the first people to be selected for COVID-19 vaccine administration. The healthcare provider administered the shot in the man’s deltoid muscle in the upper arm and applied a band-aid to cover the skin puncture. After the patient left, the provider billed the vaccine administration with CPT code 90480 and, on the same claim, appended modifier SL to vaccine code 91318 to indicate that the vaccine was state-supplied.
Note that the provider will charge $0.00 for the vaccine product – SARS-CoV-2 vaccine product (tris-sucrose formulation), 3 mcg/0.3 mL. However, the vaccine administration amount can be up to $25, depending on the Physician Fee Schedule.
Hepatitis B Vaccine Administration to High-Risk Patients
Individuals with chronic liver or kidney disease are more susceptible to hepatitis B (liver infection) than the normal population. Although the state-supplied hepatitis B vaccines are mostly reserved for eligible infants and children under the Vaccine for Children (VFC) program, providers are allowed to administer free vaccine doses to high-risk patients like those living with liver diseases or working in professions where they come in contact with bodily fluids (e.g., emergency responders and healthcare providers).
Now, think of a 55-year-old woman with a fatty liver. She visits her nearby panel hospital to get vaccinated against the hepatitis B virus. Her doctor reviews her past blood tests and abdominal ultrasound reports and informs her that she is at risk of developing complications from hepatitis B if contracted. The provider recommends a hepatitis B vaccine administration for immunization. The state-supplied vaccine is administered to the high-risk patient’s deltoid muscle in the upper arm, after which she is sent home.
The healthcare provider bills the hepatitis B vaccine administration with CPT code 90471 and, on the same claim, appends modifier SL to vaccine code 90746 for fair reimbursement.
Influenza Vaccine Administration Under the VFC Program
Every year, around 50% of children between the ages of 6 months and 17 years are vaccinated against influenza (a contagious respiratory illness caused by a virus that infects the lungs, nose, and throat). Most of these free, state-supplied vaccines are distributed through the Vaccine for Children program, which gains traction in the flu season.
Consider a 6-year-old child visiting his pediatrician for an influenza shot right before the flu season to avoid catching a fatal respiratory infection. The pediatrician’s office received a stock of influenza vaccines (under the VFC program) from the state’s health department at no cost and with the instructions to vaccinate all children aged 6 months through 17 years against the influenza virus.
The healthcare provider administered the influenza vaccine intramuscularly on the child’s upper arm, covered the skin puncture with a band-aid, and sent the child home. His staff billed the vaccine administration service with CPT code 90460 and appended modifier SL to the vaccine product code 90656 on the same claim.
Accurate Usage Guidelines for Modifier SL
Ensuring that you and your billing staff follow the billing best practices while appending modifier SL on vaccination administration claims is key to accurate and speedy reimbursement collection. Not adhering to the following guidelines can increase the chances of claim denials, so pay close attention.
Append to State-Supplied Vaccine Product Code
You must always append modifier SL to the CPT or HCPCS code that reports a vaccine product. The state can only supply immunization products (vaccination drugs) for intramuscular, oral, subcutaneous, percutaneous, intradermal, or intranasal administration at no cost to the healthcare provider. It cannot control whether the service itself (vaccine administration) will be free of charge. The providers have the right to bill insurance payers for their services.
Pair with the Accurate Vaccine Administration Code
For fair reimbursement for your services, you must be vigilant during code selection, especially while choosing the most appropriate procedural code for vaccine administration. It must accurately match the vaccine product code you injected into the patient and to which modifier SL was added.
Specify Zero-Dollar Amount for Modifier SL
If you report the vaccine product code with modifier SL to indicate that the dose was obtained at no cost from the state authorities, add $0 as the charge on the claim form. It will specify to the insurance payer that you are not charging for the state-supplied vaccine but only for your services, and they should likewise reimburse you.
Submit Vaccine Product and Vaccine Administration Codes On the Same Claim
CPT codes (or an HCPCS and CPT code) for a vaccine product and vaccine administration must be reported on the same claim form for accurate billing. For example, if you administered one unit of a state-supplied hepatitis B vaccine to a patient, your claim should include;
90471 x 1 charged $14.56
90746-SL x1 charged $0.00
Follow Payer-Specific Guidelines for Modifier SL Usage
Medicare, Medicaid, and commercial insurance payers accept modifier SL on claims. However, each payer has specific guidelines and policies for appending this modifier or billing state-supplied vaccines and their administration. You must thoroughly review these policies and billing requirements before appending the SL modifier and submitting claims to the relevant insurance payer.
Summary
Let’s quickly revisit all that we learned in this detailed guide on modifier SL to ensure you pick up on the key takeaways. We explained that the SL modifier is appended to a vaccine product code (CPT or HCPCS) to indicate that the vaccine was state-supplied and obtained at zero cost by the healthcare provider.
We also discussed a few real-world scenarios where modifier SL can be accurately applied for reimbursement, such as reporting the administration of state-supplied vaccines against COVID-19, influenza, and hepatitis B infections.
Lastly, remember, you must always append modifier SL to the vaccine product code and not the vaccine administration code to prevent claim denial.
