Same Day Immunization Administration and E/M
The National Correct Coding Initiative (NCCI) bundles evaluation and management (E/M) service and same day immunization administration (IA) codes, (e.g., CPT® 90460-90474). As a result, providers may face rejected claims when reporting an E/M service and same day immunization administration. The key to overcome these denials is to document precisely, and to append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other serviceto the appropriate E/M service code.
Significant, Separately Identifiable Are Key
Per CPT® guidelines preceding the Immunization Administration for Vaccines/Toxoids codes:
If a significant separately identifiable evaluation and management service (eg, new or established patient office or other outpatient services [99201–99215], office or other outpatient consultations [99241–99245], emergency department services 99281–99285, preventive medicine services [99381–99429] is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes.
Note the requirement that the E/M service be “significant” and “separately identifiable.” This is crucial because the NCCI includes an “edit” that disallows separate payment for an E/M service and an IA at the same visit. But, NCCI allows the use of modifier 25, appended to the E/M service code, to override the edit. By appending modifier 25, you certify to the payer that the E/M service was (as the definition of modifier 25 specifies), “significant” and “separately identifiable” — and thereby meets the CPT® requirement.
Generally, if the E/M service is unrelated to other, same-day procedures/services (in this case, the IA), you may report it separately. Or, the E/M service may be reported separately if it occurs due to exacerbation of an existing condition, or other change in patient status. If the patient arrives for a prescheduled IA, by contrast, you should not report a separate E/M service unless the patient has a new, unrelated complaint or has experienced a worsening of symptoms that prompts a new history, exam, and medical decision-making process (which could include additional testing or therapy).
To support a significant, separately identifiable E/M service, documentation of the encounter should include the required E/M components of history, exam, and medical decision-making (MDM), apart from any other procedures or services performed on the same day (including same day immunization administration). Identifying a significant, separately billable E/M service is easier if the provider documents the history, exam and MDM in the patient’s chart, and records the procedure note on a different sheet attached to the chart, or in a different section within the EHR.
Both the E/M service and the same day immunization administration must be linked to a diagnosis substantiated in the medical record (more on ICD-10-Coding for the IA, below).
Report IA With or Without Counseling
CPT® designates six codes to report immunizationadministration, depending on whether counseling is provided at the same time. For administration with counseling, select 90460-90461. To report these codes, the provider must document:
- Patient age: These codes apply only to those patients age 18 years, or younger. For patients older than 18 years old, turn to the second category of administration codes, detailed below.
- Face-to-face counseling with the patient and/or family: Parents with children often have questions about vaccines, and the provider may spend significant time on education and counseling. Documentation of the encounter should detail the vaccines given and summarize patient risk factors or concerns, and information shared with the patient/family (e.g., possible side effects and benefits of the vaccine). If the provider does not document face-to-face counseling, turn must turn to the second category of administration codes, detailed below.
- The number of vaccine or toxoid components—NOT the number of individual vaccines—administered: Report 90460 for the first component administered, and one unit of 90461 for each additional component administered.
- Route of administration (subcutaneous, intranasal, etc.) is not a factor
For administration without counseling, report instead 90471-90474. Unlike 90460/90461, these codes apply to patients of any age, and they specify the route of administration. Report 90471-90472 for percutaneous, intradermal, subcutaneous, or intramuscular injections; or, 90473-90474 for administration by intranasal or oral route.
Finally, assign codes 90471-90474 per vaccine, rather than per vaccine component.
Reporting Vaccine Supply and Diagnosis
In addition to immunization administration, you often may report the vaccine supply using a separate CPT® or HCPCS supply code. For example, to report the administration and supply of DTaP, report 90700 (DTaP Vaccine, IM).
Be sure to follow state-specific coding requirements for immunizations using vaccines supplied through the Vaccines for Children program.
Finally, note that all vaccines and immunizations are reported using ICD-10-CM code Z23 Encounter for immunization.