Internal Medicine Coding Alert

You Be the Coder:

Check Documentation Of Diagnosis For Reporting Cervical Vaccine

Published on Wed Jun 01, 2016

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Question: Our internal medicine specialist recently administered Gardasil injection for a female patient. What diagnosis code should I report for this encounter?

Kansas Subscriber

Answer: Gardasil is a vaccine that your clinician will typically administer to female patients to protect them from cervical cancer. This vaccine protects women from cervical cancer primarily by preventing infection with human papilloma virus (HPV), specifically HPV strains 16 and 18, which cause the majority of cervical cancer cases. HPV has been identified as the main causative agent for cervical cancer.

The vaccine not only prevents cervical cancer but also prevents other forms of cancer, such as anal, vulvar, and vaginal cancer. In addition, Gardasil also prevents genital warts (venereal warts), which are also caused primarily by HPV strains 6 and 11. Gardasil injections can be given to patients as young as 9 years, but the Centers for Disease Control and Prevention (CDC) recommends giving them to patients 11 to 12 years old and giving catch-up vaccinations to women up to 26 years old.

For the encounter where your internist administered Gardasil, you will need to report Z23 (Encounter for immunization).