Stick to the Facts on Childhood Immunization Coding
By Lisa Jensen, MHBL, FACMPE, CPC
According to the April 2011 Parents Magazine, 40 percent of school age children are behind on their vaccines. Measles, mumps, whooping cough, and other diseases once nearly eradicated in the United States are again on the rise. The culprit is thought to be a loss of faith in the safety and efficacy of vaccines. News headlines and Internet chatter warn of vaccines leading to autism, asthma, attention deficit hyperactivity disorder (ADHD), diabetes, etc. On the other side of the debate are many studies pointing to evidence that vaccines and their components are safe and effective.
Parents trying to determine what is best for their child often turn to the child’s pediatrician or other health care provider for advice. With all the conflicting information to sift through, providers often must spend a lot of time counseling parents prior to administering vaccines. Complete, proper coding ensures this time is fairly reimbursed.
Vaccine Timing Is Important
Each year, based on the most recent scientific data, disease experts recommend a vaccine schedule to best protect children in the United States. Changes, if needed, are announced in January. The schedule is approved by the American Academy of Pediatrics (AAP), the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians (AAFP).
The recommended vaccine schedule is influenced by several age-specific factors, such as risks for disease and complications, responses to vaccination, and potential interference with the immune system by passively transferred maternal antibodies. Taking these factors into account, vaccinations are scheduled for the earliest age group for which efficacy and safety have been demonstrated.
For many vaccines, three or four doses are needed to fully protect a child. To work best, the doses need to be spaced out. Although the vaccine schedule is considered ideal, there are exceptions for some children, including those who have an allergic reaction to an ingredient in the vaccine, a weakened immune system due to illness, a chronic condition, or are undergoing another medical treatment.
Code Administration in Two Parts
The services associated with administration of vaccines are coded and billed in two parts: one code for the vaccine and another for the administration. You must report both parts of the service to ensure accurate coding and reimbursement.
For 2011, the American Medical Association (AMA) introduced two new codes in CPT® for vaccine administration:
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 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (List separately in addition to code for primary procedure)
The new codes differ from the previous (now deleted) codes 90465-90468 in several ways. Most importantly, the previous codes were reported per immunization, whereas the new codes require you to report each component separately. A component refers to all antigens in a vaccine that prevent disease(s) caused by one organism. Combination vaccines are those that contain multiple vaccine components.
The table below shows the differences between the old and new administration codes.
|Element||90460-90461 (New Codes)||90465-90468 (Deleted Codes)|
|Routes of administration||Use for all routes of administration||Codes differed based on route of administration|
|Reported by||Component (antigen)||Immunization was single or combination|
|Age||18 years and younger||Younger than 8 years|
|Counseling provider||Required by physician or “other qualified health care professional”||Required by physician|
These changes mean that vaccine administration coding will look very different than it has in the past. More claim lines will be required to report the same services, and counting the number of components will be different now when we count vaccines. For example:
- HPV vaccine would be one component and coded as 90460
- Td would be two components and coded as 90460, 90461
- DTaP or Tdap would be three components (90460, 90461, 90461)
- DTaP-Hib would be four components (90460, 90461, 90461, 90461)
- DTaP-Hib-IPV would be five components (90460, 90461, 90461, 90461, 90461)
Counseling Is Critical
Counseling by a physician or other qualified health care professional (e.g., physician assistant or nurse practitioner) at the time of the administration is critical and a requirement of 90460 and 90461. Let’s define counseling.
CPT® requires each service billed to be fully and independently supported by medical record documentation, but does not go into specific detail about exact requirements to support the counseling of each component. Providers must provide face-to-face counseling, and then choose the format that works for them and their clinic, while still making it crystal clear which vaccine components were counseled on, and what that entailed.
For example, a note might include all vaccine components recommended at this visit, a notation that each component had counseling, and any issues discussed specific to those patient risk factors.
The documentation should support the time and effort associated with administering combination vaccines. Photocopying a statement, stamping a statement, or cutting and pasting templated documentation should be avoided. If you are concerned about your specific templates or documentation format, check with your payers to see what their payment policies are surrounding these new codes.
Some Administration Codes Carry Over
Vaccine administration codes 90471-90474 carry over from previous years, to be used for patients 19 years and older when the provider does not provide counseling, or if the health care professional providing the counseling does not meet state requirements for an “other qualified health care professional.”
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
+90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
+90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
Counseling and Non-counseling Codes Can Be Mixed
If counseling is provided for some, but not all, vaccine/toxoid components to be administered, new administration/counseling codes 90460-90461 and carry-over administration codes 90471-90474 may be reported together to accurately reflect the services rendered. For example, if counseling is performed for HPV vaccine but not for an influenza vaccine provided at the same visit, report 90460 for the HPV and 90472 (or 90474, if the second, non-counseled vaccine is administered orally or intranasally) for the influenza vaccine.
Another circumstance might occur if counseling was provided at an earlier visit, the parent has new questions or concerns at the return visit, and the physician or other qualified health care professional is asked to address these concerns. It would be appropriate to report code 90460 at the administration of a series vaccine if counseling is clearly documented during a return visit.
As a complete coding example (including administration and vaccine reporting), consider the following case:
A patient presents for her two-month well-child visit and is vaccinated for DTaP-Hib-IPV (Pentacel), pneumococcal, and rotavirus.
|CPT® Descriptor||CPT® Code||Units|
|Preventive Medicine Service||99391||1|
|First vaccine component||90460||1|
|Each additional vaccine component||90461||4|
|First vaccine component||90460||1|
|First vaccine component||90460||1|
With the discussion of childhood vaccines becoming so much more challenging, use of new codes 90460 and 90461 to adequately report and represent the complexity of these services is very important. It is clear with the increase of preventable illness in children that the role of the vaccines is still essential to ensuring the health of our communities, and coding these correctly is important to supporting this effort.
Lisa Jensen, MHBL, FACMPE, CPC, is the manager of external audits for Providence Health Plans in Beaverton, Ore. Ms. Jensen has a master’s in healthcare business leadership and an undergraduate degree in psychology with an emphasis in behavioral modification. She has spent much of the 19 years of her health care career managing teams and educating colleagues on coding, revenue cycle improvement, and compliance. Her health care experiences include physician clinics, group practices, a teaching hospital, health care consulting, and a health plan.
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