Challenges of Coding for Immunizations

by | Published on Jul 15, 2016 | Medical Coding

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Billing for vaccine administration is challenging and explains why many providers choose medical billing and coding outsourcing. There are different codes for Medicare and private insurance companies. Moreover, to correctly report immunizations for children and adults, it is important to understand what the relevant medical codes will and will not do. Professional medical coding services help ensure proper reimbursement and minimize administrative hassles.

Basics of Vaccine Coding

The factors which govern the vaccine administration codes are: route of administration (intramuscular, oral, or intranasal), the number of components in the vaccine, and for patients 18 and younger, whether the clinician counseled the patient and/or family.

  • Use ICD-10 codes Z00.121 and Z00129 for routine health check for child over 298 days old. Code Z23 may be used as a secondary code if the vaccine is given as part of a well-child visit.
  • Report Z23 for all vaccination diagnoses, including combination vaccines
  • Use Modifier-25 to report evaluation and management (E&M) services provided on the same date as a prophylactic immunization. For e.g., for a patient who receives diabetic evaluation at the same visit, code 99213-25 with diagnosis code E11.9 should be reported along with the relevant flu vaccine and administration codes.
  • A vaccine product’s National Drug Code (NDC) may need to be included when filing a claim with Medicaid and certain private payers.
  • Report pediatric immunization administration code 90460 (first vaccine/toxoid component) for immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional. Use add-on code 90461 for each additional vaccine/toxoid component.
  • Multiple units of code 90460 should be reported for each first vaccine/toxoid component administered. Multiple first components do not require a modifier.
  • Other relevant codes: 90471 for immunization administration; 90472 for each additional vaccine (single or combination vaccine/toxoid; 90743-Immunization administration by intranasal or oral route.

Codes 90460, 90471, 90461, and 90472 are reimbursed at the same rate by the 2016 Medicare fee schedule.

Documentation for Vaccine Administration with Counseling – Points to Note

  • Codes 90460 and 90461 require counseling related to the vaccinations by the physician or other qualified healthcare professional for patients 0 through 18 years of age.
  • The “adult code” 90471 does not specify age or mention counseling in any way, and in the absence of counseling, the administrations must be reported with adult codes 90471-90474.
  • The parenthetical instructions relating to adult codes refer to “separate and significant” E&M services. Therefore, if these services are provided, the vaccine and toxoid administration codes should be reported along with the appropriate E&M service code.

All procedure codes include the amount of discussion related to the procedure or specific vaccinations normally included or considered necessary to responsibly complete the procedure. Even if there is any additional discussion, experts advise using an E&M code. The provider can include details of the discussion the specifics of that patient’s concerns related to a given vaccine to indicate time/technical skill spent without altering the RVU of code 90471.

With all these challenges, outsourcing medical billing and coding tasks to an experienced medical billing and coding company is the best way to manage the nitty-gritty of coding vaccines for optimal reimbursement.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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