Vaccination Administrations in Pediatric Practice

Vaccination Administrations in Pediatric Practice

Be diligent with documentation review to overcome coding challenges.

There are several things you need to determine to capture the appropriate administration code(s) for vaccinations, such as:

  • Was counseling provided by the provider?
  • How many vaccinations were administered?
  • What was the route of administration?
  • How many components/toxoids were there in each vaccination?

In 2011, two new CPT® vaccine administration codes (90460 and +90461) replaced 90465-90468. The new codes differ greatly from existing codes 90471-90474, in that they include counseling by the physician or other qualified healthcare provider and are billed based on the number of components instead of the number of vaccinations given, as shown in Table A. The route of administration is not part of the two new codes.

CPB : Online Medical Billing Course

Table A: Vaccine administration codes

CPT® Code Code Descriptor
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
+90472 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 each additional vaccine (single or combination vaccine/toxoid)
(List separately in addition to code for primary procedure)
90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
+90461 each additional vaccine or toxoid component administered

(List separately in addition to code for primary procedure)

Let’s look first at 90471-90474, which are used when a provider does not counsel the patient on the vaccines administered. CPT® 90471 and +90472 are for vaccines administered via intramuscular injection, which is the most common route of administration; 90473 and +90474 are for vaccines administered via an intranasal or oral route.

Multiple Vaccine Administrations

Codes 90471 and 90473 are for the initial or first vaccine administered. Remember: Only one initial administration code can be used at a given encounter. When multiple vaccines are administered, bill each additional vaccine administration with +90472 and/or +90474. These are add-on codes that require you to report 90471 or 90473 as the main code. When both an injectable and an oral/intranasal vaccine are administered during the same visit, report 90471 as the initial administration code.

When three or more vaccines are performed during the same visit, apply additional units to the subsequent administration code for each additional vaccine of the same route (injection or oral/nasal.)

Here are some examples of multiple vaccination administrations:

Example 1:

3 intramuscular injections

90471 x 1 unit for the initial intramuscular vaccination administration

+90472 x 2 units for each additional intramuscular vaccination administration

Example 2:

1 intramuscular injection and 1 oral administration

90471 x 1 unit for the initial intramuscular vaccination administration

+90474 x 1 unit for the additional oral administration

Example 3: 

2 intramuscular injections, 1 oral administration, and 1 nasal administration

90471 x 1 unit for the initial intramuscular vaccination administration

+90472 x 1 unit for the additional intramuscular administration

+90474 x 2 units for the additional oral/nasal administrations

Example 4:

1 oral administration and 1 nasal administration

90473 x 1 unit for the initial oral/nasal administration

+90474 x 1 unit for the additional oral/nasal administration

Vaccine Administration with Counseling

Next, let’s look at vaccine administration when counseling is provided and billed with 90460 or +90461. The coder must determine how many vaccines were administered, as well as how many vaccine/toxoid components are contained in each vaccine. The route of administration is no longer a factor in the code selection.

CPT® 90460 is for the first component and 90461 is for each additional component. A component is the antigen that makes up the vaccine for a specific disease. All vaccines include a minimum of one component (here’s where it’s important for you to know how many vaccines were administered). For example, if three vaccines are administered with counseling, at minimum, 90460 is billed three times.

Some vaccines have a single component and some have multiple components. CPT® 90716 Varicella virus vaccine, live, for subcutaneous use is an example of a single component vaccine, since it only includes the component for fighting the varicella (chicken pox) virus. CPT® code 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use is a multi-component vaccine. It includes three components, as it fights against three different viruses.

Here are some examples for coding counseling with vaccine administration:

Example 1:

Varicella (1 component) and MMR (3 components) vaccines administered

90460 x 2 units for the first component in each of the two vaccines administered

+90461 x 2 units for the additional two components in the MMR vaccine administered

Example 2:

Hepatitis A (1 component), MMR (3 components) and diphtheria, tetanus, and acellular pertussis (DtaP) (3 components) vaccines administered

90460 x 3 units for the first component in each of the three vaccines administered

+90461 x 4 units for the two additional components in the MMR vaccine and two additional components in the DtaP vaccine

Remember to code 90460 for every vaccine administered with counseling given, rather than reporting 90460 only once for the total number of vaccines administered at the visit. If an individual vaccine includes multiple components, code +90461 for each additional component included in the vaccine.

Also remember that the documentation in the medical record must support that counseling was performed. The provider should document that he or she counseled on XYZ vaccine(s), with a description of what the counseling included (i.e., risk and benefits, side effects, etc.).

Reimbursement

Vaccine administration is an area in which a pediatric practice may experience missed revenue. Perhaps counseling was given, but the provider did not document this; or maybe it was documented, but the billing sheet did not indicate such. As you can see in Table B, the work relative value units (RVUs) and reimbursement for the initial administration codes are the same as the codes for the first component with counseling; however, more codes may be billed for those instances when counseling was provided.

Table B: Medicare reimbursement

CPT® Code w/RVU Medicare Reimbursement
90471 0.1700 $25.51
+90472 0.1500 $12.94
90473 0.1700 $25.51
+90474 0.1500 $12.94
90460 0.1700 $25.51
+90461 0.1500 $12.94

For example, a patient receives an MMR vaccination. Without counseling by the physician, the vaccine administration is billed 90471, with a reimbursement of $25.51. If the physician provides counseling on this vaccination, the administration could bill 90460 and +90461 x 2. An MMR vaccination consists of three components; 90460 is billed once for the first component with a reimbursement of $25.51 and +90461 is billed twice (once for each additional component) for a reimbursement of $25.88. This gives a total reimbursement of $51.39.

Vaccines for Children Program

Keep in mind that some medical practices participate in the Vaccines for Children (VFC) program. This is a program in which the state provides a medical practice with vaccines to be administered to children under the age of 18 who meet certain criteria. In this situation, physicians may not charge the beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers for the vaccine product. However, providers may charge the administration fee associated with providing the vaccine. For vaccines provided as part of a VFC program, you may be required to follow alternate coding methods. Check with your state VFC program and local carriers for specific rules.

As you can see, vaccine administration can pose some challenges. Be diligent in reviewing the documentation to ensure proper coding and maximum reimbursement for these services.


 

Ellen Hinkle, BS, CPC, CPC-I, CPMA, CEMC, CIMC, CFPC, has over 17 years of medical billing and coding and consulting experience. As a coding auditor for Visionary Health Group in Indianapolis, Ind., she is primarily responsible for chart reviews, provider education, and teaching billing and coding classes including the AAPC’s PMCC curriculum to prepare students for the Certified Professional Coder (CPC®) exam. Hinkle is a member of the Indianapolis, Ind., local chapter.

2017-code-book-bundles-728x90-01

Leave a Reply

Your email address will not be published. Required fields are marked *