Pediatric Coding Alert

Apply 90465-90468 when visit meets age, counseling criteria

You will finally have a way to bill prevaccine counseling, thanks to CPT 2005's introduction of four new immunization administration codes. 

The American Academy of Pediatrics (AAP) has been struggling to get the Centers for Medicare & Medicaid Services (CMS) to recognize the work that physicians perform when administering vaccines.

CMS previously didn't assign a physician work component to vaccine administration codes, says Linda Walsh, senior health policy analyst with the AAP division of healthcare finance and practice. "The AAP has been trying to find a way to make vaccine work payment palatable to the CMS."

Administering vaccines to children involves more work than giving shots to adults. "Physicians give the majority of vaccines to children under 8 years old," Walsh says. Because the AAP showed CMS the added prevaccine work that child vaccine administration requires, the CPT Panel approved four new codes, she says.

Learn the New and Old Pre-Immunization Codes You Can Use

CPT 2005 will include eight vaccine administration codes. "It will contain the four existing codes 90471-90474, and four new codes 90465-90468," Walsh says.

Here's how the new codes appear:

90465 - Immunization administration under 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

+90466 - ... each additional injection (single or combination vaccine/toxoid), per day (list separately in addition to code for primary procedure)

90467 - Immunization administration under 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

+90468 - ... each additional administration (single or combination vaccine/toxoid), per day (list separately in addition to code for primary procedure).

The old codes, which include editorial revisions to 90471-90472, read:

90471 - Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)

+90472 - ... each additional vaccine (single or combination vaccine/toxoid) (list separately in
 addition to code for primary procedure).

* Change: Codes 90471-90472 eliminate "jet injections." Physicians weren't using this method to administer immunizations, so CPT removed the reference.

90473 - Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)

+90474 - ... each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure).

* Relief: These codes remain the same in 2005.

Choose Code Set Based on Age, Counseling

You can easily keep the new and old code sets straight. Starting Jan. 1, you should use the new immunization administration codes (90465-90468) when the encounter meets two criteria:

1. the child is under age 8

2. "the pediatrician performs the face-to-face vaccine counseling regarding vaccine product, possible reaction and addressing parental concerns," says Richard Tuck, MD, FAAP, a member of the AAP national committee on coding and nomenclature.
 
If the vaccine administration doesn't meet the age and physician requirements, you would report the old codes (90471-90474).

Example: A nurse counsels a 6-year-old child's mother on vaccine benefits, risks and reactions and has the mother sign the consent form. In this case, you wouldn't use the new codes (90465-90468), Walsh says. "In 2005, you will instead revert to the old codes (90471-90474)."

Why: The encounter doesn't meet both new code requirements. The 6-year-old meets the age requirements. But because the nurse does the counseling, the encounter doesn't qualify as 90465-90468.