Immunization Reporting Requires Multiple Codes
By Arlene J. Smith, CPC, CCS-P
When should you report an immunization code? And how exactly do you decide which codes to use? These are questions every seasoned coder has faced at one point or another.
During the immunization process, a patient is exposed to a small amount of a virus or toxin. In response, the body’s immune system activates and builds antibodies against that particular virus or toxin. The next time the body encounters the virus or toxin, an automatic response activates the antibodies, which attack the intruder. The threat from the virus or toxin is eliminated, making the patient immune to that substance. Immunizations are usually accomplished via injection, but some are introduced orally or with a nasal spray.
Many people interchange the words immunization and vaccination. The word immunization refers to all types of substances, such as immune globulins, vaccines, or toxoids. When referring to a vaccination, most people are thinking of vaccines, such as measles, mumps and rubella.
In the Medicine section of the CPT® codebook, you’ll find three distinct groups of codes relating to immunizations:
- Immune globulins-found in 90281-90399
- Administration codes for immunizations-found in 90465-90474
- Vaccines/toxoids-found in 90476-90749
Besides these codes, there are codes for some products in the “J” codes section of the HCPCS Level II code book. It’s important to remember that coders must report codes for both the administration of the injection and the supply of vaccine/toxoid.
There are a total of eight codes in CPT® for reporting the administration of immunizations. If you look at them closely, there are actually four sets of two codes. The primary administration code is followed by an “add-on” code with the “+” designation listed in front of the code number. In each case, the primary code is for the first injection of a single or combination vaccine/toxoid. For each additional injection, an add-on code would be used.
Each code set describes which population and which route of immunization administration they relate to. For example, 90465 and 90466 are specifically for patients younger than 8 years old; they include percutaneous, subcutaneous or intradermal routes of administration, and are used when the doctor counsels the family prior to the immunization. The codes 90467 and 90468 are similar except the route of administration is intranasal or oral. The age of the patient and counsel of the family are the same.
For patients over the age of 8 years, codes 90471 and 90472 are used for percutaneous, subcutaneous and intradermal administration. The 90473 and 90474 codes are used for the intranasal or oral route of administration. There is no reference to counsel of the patient or family in these codes.
Once you have figured out how to report the administration of the immunization based on the above advice, you need to figure out how to report what was actually administered. There are two different resources—CPT® and HCPCS Level II—to use when determining the correct code. Do not append modifier 51 to vaccine/toxoid product codes.
CPT® codes are developed and assigned by the AMA (American Medical Association). HCPCS Level II codes have been developed and are assigned by CMS (Centers for Medicare and Medicaid Services). A few of the substances used in immunizations have assigned codes in both resources. Remember that in CPT® the immune globulins are found within 90281 to 90399 and the vaccines/toxoids are within 90476 to 90749. The substance codes in HCPCS Level II are found in the J code section. Payers may have specific instructions as to which code, CPT® or HCPCS Level II, they want reported with the immunization administration codes.
As you review the vaccine/toxoid code choices in CPT® you will notice that many of the vaccines are listed individually and in specific combinations. It is important to choose the correct code and bundle the combinations. In childhood vaccines, there are any number of combinations for MMR, DTP, varicella, Hib, polio and hepatitis. If several vaccines are listed for the patient, be sure to check all of the possible combinations in CPT® before assigning the code.
The other code to assign correctly is the appropriate ICD-9-CM diagnosis code. For prophylactic immunizations, these are generally found in the V code section of ICD-9-CM under V03, V04, V05, and V06. There are specific conditions listed for these codes, and for conditions not listed, there are options for “specified” or “unspecified” conditions.
The following are a few examples of how you should code for different types of immunizations:
A two-year-old patient presents for the MMR (measles, mumps, rubella) combination vaccine, an oral polio vaccine, and needs to start the Hepatitis B series of immunizations.
90465 Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day
90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
V06.4 Need for prophylactic vaccination against the combination of measles-mumps-rubella (MMR)
90466 Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
V05.3 Need for prophylactic vaccination against viral hepatitis
90468 Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
90712 Poliovirus vaccine, (any type(s)), (OPV), live, for oral use
V04.0 Need for prophylactic vaccination against poliomyelitis
An eighteen-year-old, female patient presents requesting the new HPV vaccine.
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
90649 Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use
V04.89 Need for prophylactic vaccination against viral diseases; or
V05.8 Need for prophylactic vaccination against other specified disease, depending on insurer preference
In either of these examples, if the physician also sees the patient for a problem or preventive exam, the appropriate E/M code would be added with modifier 25 appended to indicate that the E/M is a significant and separately identifiable service and should not be bundled into the immunizations.
Remember third-party payers may have specific coverage rules or coding guidance for reporting immunizations, so it is always a good idea to check with your payers before sending claims. There may be specific consent forms to obtain, or preauthorization requirements for some vaccinations.