Immunization Administration Points to Ponder for 2011
By Ken Camilleis, CPC, CPC-I, CMRS
For 2011, CPT® codes 90465, 90466, 90467, and 90468—used for reporting immunization administration with counseling—are deleted, and replaced by two new 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 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)
When determining whether these new codes apply, consider the following three key factors.
Point 1: Scope of Practice Determines Who Counsels
The purpose of counseling during an encounter for vaccine or toxoid administration is to address concerns or questions that may arise regarding the benefit of a vaccine, or to allay fears about side effects of a particular agent. Counseling may be provided to a child and his or her parents, or other family members, caregivers, or anyone else responsible for the child’s well-being when presenting for vaccinations.
Deleted codes 90465-90468 specified within their descriptors, “when the physician counsels the patient/family.” This commonly was interpreted to mean that only a doctor of medicine (MD) or a doctor of osteopathy (DO) was qualified to report these codes—although, some observers interpreted “physician” more broadly to include mid-level providers.
To reduce this confusion, 90460 and 90461 now have replacement language that specifies, “counseling by physician or other qualified health care professional.” A question remains, however: What constitutes a “qualified” health professional? The answer largely is determined by scope of practice regulations, which vary from state to state.
Scope of practice is a concept defined by state licensing boards to identify services that a licensed individual is authorized to perform legally, based on that individual’s pertinent education and experience. This means each state’s scope of practice provisions determine whether a medical practitioner is qualified to provide (and bill for) counseling in relation to pediatric/adolescent immunization administrations.
There are three distinct groups of health care practitioners that provide medical services: top-level providers, mid-level providers, and auxiliary (ancillary) staff. Top-level providers are board-certified. In any state, a top-level provider such as an MD or DO can report counseling of patients or parents for an immunization if the counseling is documented properly in the patient’s medical record.
Mid-level providers have at least a bachelor’s degree in medicine or nursing. Examples are:
- Advanced nurse practitioners/advanced registered nurse practitioners (ANPs/ARNPs)
- Clinical nurse practitioners (CNPs)
- Registered nurses (RNs)
- Physician assistants (PAs)
Based on their education, CNPs, ANPs, ARNPs, and RNs would qualify under scope of practice criteria to report 90460 and 90461. Depending on the payer, however, the mid-level provider may be reimbursed at less than the relative value unit (RVU) or contracted rate, per Medicare’s incident-to provision. Mid-level providers other than CNPs, ANPs, ARNPs, and RNs may be governed by their state’s scope-of-practice laws as to whether they may report 90460 and 90461, or whether they may report only immunization without counseling (90471-90474).
Auxiliary staff, such as licensed practical nurses, nursing assistants, and other medical staff assistants, may have no formal degree. According to AAP, such clinical staff does not qualify as providers who may report vaccination counseling services.
My recommendation when coding any pediatric or adolescent vaccine or toxoid administration with counseling is that documentation clearly identifies who (including title(s)) provided the counseling to parents, with proper signatures to verify the level of provider qualification. I also recommend that providers and coders periodically visit their state government’s website and search under their insurance division to remain abreast of scope-of-practice regulations for mid-level providers, with regard to reporting and reimbursement of 90460 and 90461.
Point 2: Vaccine/Toxoid “Components” Are Separately Coded
Secondly, consider the meaning of the word “component” in the descriptors for 90460 and 90461. According to the AAP, a component refers to all antigens in a vaccine that prevent diseases caused by one organism. Combination vaccines are those that contain multiple components. The extra practitioner work involved in administering multiple component vaccines/toxoids is considered and each component is reported separately.
For example, a DTaP consists of three components (diphtheria, tetanus toxoid, and acellular pertussis) so the reporting of DTaP with counseling would be:
- 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use, for the vaccine itself
- 90460 for administration with counseling of the first component (diphtheria)
- 90461 x 2 for administration with counseling of the second and third components (tetanus and pertussis)
Note that the first component code (90460) resets within the same claim if more than one vaccine is administered. For example, a 5-year-old boy was administered DTaP and MMR with parent counseling. In this case, the coding for the DTaP would be (in no particular order, but depending on the payer): 90700, 90460, 90461 x 2; and for the MMR:
- 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use, for the vaccine itself
- 90460 for administration with counseling of the first component (measles)
- 90461 x 2 for administration with counseling of the second and third components (mumps and rubella)
Point 3: Patient Age Affects Coding
Previous immunization with counseling codes 90465-90468 applied to patients younger than eight years of age. New codes 90460 and 90461 apply to all patients “through 18 years of age,” or up through the day before the patient’s 19th birthday.
As in the past, if a patient of any age presents for vaccinations, but there has been no billable counseling, the administration(s) must be reported with codes 90471-90474.
Based on information on the American Academy of Pediatrics (AAP) website, counseling (90460/90461) and non-counseling (90471-90474) immunization codes may be reported together; however, both the AAP and the Centers for Disease Control and Prevention (CDC) recommend that a physician or other qualified professional counsels patients and family about the risks and benefits of all vaccines administered at a particular setting, including discussions of previous side effects, the potential impact of a new illness, and possible contra-indications to the administration of an agent.
Kenneth Camilleis, CPC, CPC-I, CMRS, is a medical coding and billing specialist whose present focus is coding education. He is a full-time PMCC instructor and part-time educational consultant. Last year he was the education officer for his local chapter.