Pediatric Coding Alert

Children may not mind getting fewer shots than they need, but parents and pediatricians try to prevent anyone from getting behind in their immunizations. Nevertheless, this sometimes happens. And, the fact that they are behind may not be discovered until the child comes in for another problem.

When a child comes to our office for a middle ear effusion and we realize she is behind in her immunizations, what diagnosis code should we tag to the immunizations? asks John F. Norton, MD, FAAP, of Corydon, IN. Should we use a modifier?

Specific Diagnosis Codes

The answer is to use the diagnosis codes for the specific immunizations.

Use the diagnosis code for the vaccine being given, says Karen West, coding specialist for Miller Medical Group, a multi-specialty group practice in Nashville, TN with eight pediatricians (17 physicians altogether).

Often there is a question about what code to use for DTaPthe closest diagnosis code is V06.1, which is for DTP. There is no code for the acellular version, which is what is usually given now. DTP is the same as DTaP for diagnostic coding, says West. So you should use V06.1 for DTaP.

Barbara Duff, billing clerk for Greater Chesapeake Medical Group, a multi-specialty practice in Annapolis, MD, agrees. Use the diagnosis code for the particular shot youre giving, if its not part of a well visit, says Duff. And so does Cheryl Kunkel, financial supervisor of medical centers for the Northern Pediatric Center, a three-pediatrician practice in Mount Airy, NC. We use the actual vaccination codes in a situation like that, says Kunkel.

What these codersand Norton, who was using the correct diagnosis codes but just wanted to make sure he was doing it properlyknow is that they cant use V20.2 , the diagnosis code for a routine infant or child health check, if they are giving the immunizations at a time other than the well visit. The diagnosis code wont match the procedure code, which will be for a sick visit (the ear effusion, in Nortons case) as well as the procedure codes for the shot.

Tip: Its up to the pediatrician to make sure the child who comes in for a sick visit is well enough to get the immunizations. Most insurance companies allow us to determine if the child is okay to get the vaccine says Kunkel.

No Modifier, No Nurse Visit

No modifier is necessary to bill for a sick visit and an immunization code, our sources note. You would not use a nurse visit (99211) if the child is also being seen by the doctor for a sick visit. You cant tack on a nurse visit, even with a modifier, says West.

Kunkel never uses a nurse visit for immunizations, even
when the patient comes in for nothing else. (This sometimes happens. For example, the pediatrician may decide during the well-visit that the patient shouldnt receive immunizations on that day because of an ongoing infection, which the physician has just discovered.) Kunkel is in North Carolina, where the state pays for all vaccines. They pay us administration fees of $13.71 for one immunization, and $27.42 for two or more, says Kunkel.

If I had an office visit, I wouldnt get a nurse visit (99211) too, concurs Duff. But, if the patient comes in for the shots and nothing else, then I would use a 99211.

Vaccination Diagnosis Codes V03.2 Tuberculosis V03.5 Diphtheria alone V03.6 Pertussis alone V03.7 Tetanus toxoid alone V03.81 Hemophilus influence, type B (Hib) V04.0 Poliomyelitis V04.1 Smallpox V04.2 Measles alone V04.3 Rubella alone V04.6 Mumps alone V04.8 Influenza V05.4 Varicella V06.1 Diphtheria-tetanus-pertussis, combined (DTP) V06.3 Diphtheria-tetanus-pertussis with poliomyelitis (DTP + polio) V06.4 Measles-mumps-rubella (MMR) V06.5 Tetanus-diphtheria (Td) V06.8 Other combinations