Physicians who administer the HPV vaccines and medical billing and coding companies need to be well-informed about reporting these services correctly to optimize practice reimbursement.
Genital human papilloma virus (HPV) is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Some HPV types can cause cancer. According to the American Academy of Pediatrics, more than 26 000 new cases of HPV-related cancers are diagnosed annually in the United States. HPV infection is responsible for the majority of cases of cervical cancer, making vaccination a critical part of prevention of condition. A study on the prevalence of HPV after introduction of the vaccination program in the US found that compared to the pre-vaccine era (2003-2006), HPV prevalence declined in the vaccine era (2009-2012) by 64% in 4vHPV type prevalence among girls 14 through 19 years of age and by 34% among women 20 through 24 years of age. These statistics highlight the impact of the HPV vaccine.
HPV vaccine administration
HPV vaccine is approved by FDA and is recommended by CDC for both males and females. HPV vaccination is recommended for 11 and 12 year-old girls. Rather than the previously recommended three doses, they get two doses of HPV vaccine, with the second dose to be given 6-12 months after the first dose. HPV vaccine is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series, and can also be given to girls beginning at age 9 years. Those starting the series ages 15 to 26 will need three doses of the vaccine to protect them from infection. The vaccine is not recommended for pregnant women.
The only HPV vaccine available in the United States is GARDASIL 9. GARDASIL 9 is indicated in females 9 through 26 years of age for the prevention of cervical, vulvar, vaginal, and anal cancers caused by human papilloma virus (HPV) Types 16, 18, 31, 33, 45, 52, and 58; precancerous or dysplastic lesions caused by HPV Types 6, 11, 16, 18, 31, 33, 45, 52, and 58; and genital warts caused by HPV Types 6 and 11.
HPV pediatric vaccine CPT (product) codes
CPT code 90649 – Human Papilloma virus vaccine, types 6, 11, 16, 18 quadrivalent (HPV4), 3 dose schedule, for IM use (brand GARDASIL)
CPT code 90651 – Human Papilloma virus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for IM use (*Use also for 2-dose schedule*) (brand GARDASIL 9)
On January 1, 2017, the American Medical Association announced revision of code 90651 to include the new FDA approved 2-dose schedule, which will be effective July 1, 2017 as:
Revision of code 90651 – Human Papilloma virus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use
Reporting pediatric immunization administration
90460 and 90461 are pediatric immunization administration codes:
- 90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component
- +90461: Each additional vaccine/toxoid component (list separately in addition to code for primary procedure)
Points to note:
- Codes 90460 and 90461 indicate immunization administration, and purchased vaccine products must be separately reported.
- Use 90460-90461 to report a face-to-face service where a physician or other qualified health care professional (qualified per state licensure) provides counseling to the patient and/or caregivers is required.
- If counseling does not take place, the administrations must be reported with codes 90471-90474.
- 90460-90461 should be reported for vaccine administration to patients 18 years of age and under.
- Code 90460 is reported for each separate administration of single component vaccines and/or first component of a combination vaccine.
- To report administration of combination vaccines, report code 90460 for the first component and add-on code 90461 for each additional component (modifier -51 is not required).
- Since the codes include “via any route of administration” the route of administration does not matter.
When an evaluation and management (E/M)service (other than a preventive medicine service) is provided on the same date as a prophylactic immunization, modifier -25 may be appended to the code for the E/M service to point out that this service was significant, and distinct and separate from the physician’s vaccine counseling/administration work.
Reporting HPV vaccine product and administration codes is much easier with outsourced medical billing and coding services. Up-to-date with the latest developments in the field, an experienced service provider can help physicians code and bill correctly to avoid denials and optimize reimbursement.