Don’t Let Vaccines Poke Holes in Your Practice’s Pockets
By Lisa Jensen, MHBL, FACMPE, CPC
Each year, a team of top disease experts and practice physicians work together to decide what changes will be made to the childhood immunization schedule, which helps protect U.S. children and adults from diseases. The schedule (www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable) is evaluated based on the most recent scientific data available. Changes are announced in January and approved by the American Academy of Pediatrics (AAP), the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians (AAFP). Providers receive notice of the changes, and are expected to purchase and administer the immunizations to fit the new schedule.
Over the last several years new and expensive vaccines added to the schedule for adolescents, adults, and children have created a financial hardship for providers trying to balance economic pressures and best practices. A survey commissioned by the National Vaccine Advisory Committee (NVAC) reported that 62 percent of decision makers in practices delayed purchase of a vaccine some time within the past three years due to financial concerns. The survey revealed that in the prior year 16 percent of practice decision makers seriously considered stopping vaccinations for privately-insured patients due to high cost and reimbursement issues.
Offset High Costs with Appropriate Billing
How can practices continue to protect the communities they serve, prevent disease outbreak, and maintain financial viability? One way is to report the vaccines and vaccine-related services accurately, and bill appropriately. You should report vaccine administration using two families of CPT® codes: One for the vaccine itself and one for the vaccine’s administration.
To facilitate immunization reporting, the most recent new or revised vaccine product codes, resulting from recent CPT® Editorial Panel actions, are published on the American Medical Association (AMA) CPT® website on July 1 and Jan. 1 in a given CPT® cycle. These dates correspond with CPT® Editorial Panel meetings for each CPT® cycle (June, October, and February).
Watch for a lightning bolt symbol that was added to CPT® in 2006 for vaccine codes pending approval from the Food and Drug Administration (FDA). A full list is in Appendix K. These are normally not reimbursed until the FDA approves the vaccine but have been assigned codes pending approval, which often happens during that CPT® cycle.
Correct Vaccine Reporting
Use CPT® code range 90476-90478 to report the vaccine or toxoid product only, based on the produce manufacturer and brand, the specific schedule, chemical formulation, dosage, patient’s age, and/or route of administration. The exact vaccine provided must be reported this way to meet the requirements of immunization registries, vaccine distribution programs, and other reporting systems that track usage and administration of vaccines.
With the dizzying array of vaccine producers and product names, it’s challenging to keep the CPT® and ICD-9-CM codes straight. The AAP provides a free table with an easy-to-follow format allowing coders to access the correct CPT® and ICD-9-CM code by knowing either the manufacturer or brand name. This resource can be found on the AAP website at http://practice.aap.org/content.aspx?aid=2334&nodeID=2002.
Be Cautious with Combination Doses
Codes are available for either individual vaccines or combination vaccines. Combination vaccines are formulations of antigens that combine multiple vaccines into a single injection (for example, 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use). It is not appropriate to report the components of a combination vaccine when a single CPT® code exists to report the combination.
Report Vaccine Administration Separately
CPT® code range 90465-90474 reports the administration of the vaccine. Report these codes separately from the CPT® code representing the vaccine product itself. These codes are reported based on the route of immunization, the patient’s age, the number of injections, and the product administered.
Each family of codes contains a code for the “first” or “one” immunization administration.
CPT® codes 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 and 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) are reported for the first vaccine administered by the injection route to a patient on a calendar date.
Codes 90467 Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day and 90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid) are reported for the first vaccine administered by the oral or intranasal route to a patient on a calendar date.
Coding Quandary: Two Different Routes on the Same Calendar Date
Confusion arises for both payers and providers when the patient requires multiple vaccines on the same date, but administered via different methods. In this scenario, report one vaccine administration code that indicates “first,” and report the other route as an additional vaccine.
For example, a patient is receiving injectable hepatitis B vaccine and intranasal influenza vaccine. Report the vaccine administration using 90471 and +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).
Physician Face-to-Face Vaccine Counseling
CPT® contains pediatric-specific vaccine administration codes (90465-90468) with special requirements. To report 90465-90468, the patient must be younger than eight-years-old and the physician must perform face-to-face counseling personally. These special codes include the provider work of discussing risks and benefits of the vaccines, the cost of the nursing time to record and give the vaccine, plus the supplies associated with vaccine administration. To support these codes, the medical record must include the physician’s personal involvement in the parent/family counseling about the vaccine’s risks and benefits.
If the patient is eight years or older, and/or the physician does not personally perform the face-to-face counseling, report a CPT® code from range 90471-90474.
In CPT® 2009, the AMA clarified that vaccine counseling is not included in the Preventive Medicine Visits code range 99381-99397. The CPT® book instructs coders to report immunization and vaccine risk/benefit counseling separately when performed on the same day as a preventive service.
If your practice is having trouble getting the vaccine counseling/administration codes reimbursed with other services, the Childhood Immunization Support Program (CISP) site, in cooperation with the AAP, provides information that you can share with your payers, explaining the vaccine work that is and is not included in the reimbursement for other services. Find the link at www.aap.org/immunization/
A six-month-old patient presents to your practice requiring a diphtheria, tetanus toxoids and acellular pertussis vaccine (DTaP), a Haemophilus influenzae type b (Hib), pneumococcal (PCV), and annual influenza. The parent has read a disturbing article in a magazine regarding the risks of (DTaP) vaccines, and your provider must spend time face-to-face with the parent addressing DTaP concerns, and providing additional risks/benefits discussion. The nurse provides the information sheet and additional discussion specific to the Hib, PCV, and influenza vaccines.
Coding for this service would be:
90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use. This code is for the DTaP vaccine product.
90465 This code is for the immunization administration of the first vaccine including face-to-face counseling with the provider.
90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use. This code is for the Hib vaccine product.
+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). This code is for the “additional” administration of the Hib vaccine with counseling by the nurse.
90669 Pneumococcal conjugate vaccine, 7 valent, for intramuscular use. This code is for the PCV vaccine product.
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). This code is for the additional administration of the PCV vaccine with counseling by the nurse.
90660 Influenza virus vaccine, live, for intranasal use. This code is for the intranasal influenza product.
+90474 This code is for the “additional” administration of the influenza vaccine by intranasal route.
Vaccines for Children (VFC) Program
Since its inception, the VFC Program has helped shift the nationwide vaccine delivery system away from public health and more toward private providers. VFC has accomplished this by providing free vaccines to primary care physicians, attempting to keep children in their “medical home” (their regular source of primary care), with the goal of decreasing private provider patient referrals to public health for immunizations.
Free vaccines are available to children who are under 19 years of age, and who meet any of the following criteria:
- Enrolled in the Medicaid program
- Do not have health insurance
- Have no coverage of immunization on their health plan
- Are American Indian or Alaskan Native
VFC vaccines are provided free to participating physicians, and patients/insurers can only be charged for the administration. Providers bill according to CPT® codes based on each vaccine (type of immunization) administered. Reimbursement through Medicaid varies by state. Some state Medicaid agencies reimburse a vaccine with multiple antigens at a higher rate than a single antigen vaccine. Some states limit the amount of administration fees reimbursed per visit. Check with your state Medicaid agency to determine how the VFC administration fees should be coded and reimbursed. This program is a good way to provide important immunity while preventing reimbursement problems.
The diagnosis code accompanying the vaccine administration and vaccine product CPT® code typically is specific to the disease for which the patient is being inoculated, from range V03-V06. Some payers only require the diagnosis V20.2 Routine child health exam or V20.31 Health supervision for newborn under 8 days old or V20.32 Health supervision for newborn 8 to 28 days old if the vaccines are administered as part of a complete physical on the same calendar day.
There are many reasons why an immunization may not be given, but the ICD-9-CM book has in the past only provided coders with a single code. Tracking why an immunization was not given can be as important as tracking those that are given. The AAP has requested and recently received additional codes to identify the different reasons why a patient did not receive a routine immunization. Be sure to indicate these circumstances in your practice when they apply:
V64.00 Vaccination not carried out, unspecified reason
V64.01 Vaccination not carried out because of acute illness
V64.02 Vaccination not carried out because of chronic illness or condition
V64.03 Vaccination not carried out because of immune compromised state
V64.04 Vaccination not carried out because of allergy to vaccine or component
V64.05 Vaccination not carried out because of caregiver refusal
V64.06 Vaccination not carried out because of patient refusal
V64.07 Vaccination not carried out because for religious reasons
V64.08 Vaccination not carried out because patient had disease being vaccinated against
V64.09 Vaccination not carried out because of other reason
The nation’s providers are soldiers in the campaign to vaccinate America’s citizens, but the soaring cost and rising number of new vaccines make it difficult for them to buy the shots that are often under-reimbursed. With correct coding and accurate billing of all services rendered, coders can be an important part of keeping their patients healthy.
Lisa Jensen, MHBL, FACMPE, CPC, is the manager of the Special Investigations Unit at Providence Health Plans in Beaverton, Ore. She holds a master’s degree in Healthcare Business Leadership, has been a CPC® since 1996, and attained Fellowship status in the American College of Medical Practice Executives (FACMPE) in 2008.
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