Pediatric Coding Alert

Expansion of the federal Vaccines for Children program to include private pediatric practices has been a godsend for uninsured and underinsured children who might not otherwise be able to get needed immunizations. However, correctly coding and accounting for these vaccines has been a challenge for many pediatric practices.

Pediatricians administering the vaccines need to collect an administration fee for giving the shots, but cant code the regular CPT code if they recieve the vaccine for free. And, even if they get the shots without cost, they must document the number and type of vaccines given.

Background

Coding for state-supplied vaccines depends largely on what is happening in your state. The federal Vaccines for Children (VFC) program is designed to make sure every child in the country is immunized, regardless of income or insurance coverage.

In most states, to be eligible for VFC vaccines, children must either be enrolled in Medicaid, uninsured, American Indian or Alaskan native, or underinsured (with medical insurance that does not cover immunizations), and underinsured children must go to a public health clinic for the vaccines.

Some states, however, have discovered that this creates fragmentation in health care, and they have allowed all practices to receive free vaccines. In these states, underinsured children do not have to go to clinics for immunizations, but can get them directly from their pediatricians.

There are also universal states which allow all chldren to receive free vaccines. These universal states are Alaska, Colorado, Connecticut, Idaho, Maine, Massachusetts, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, Rhode Island, South Dakota, Vermont, and Washington. In these states, pediatricians do not purchase vaccines from pharmaceutical companies; the states do, and then give them to pediatricians for free.

You need to contact your state VFC representative for particulars on how the program works in your state.

The Administration Fee

When billing for these state-supplied vaccines, there are two key points to remember: one is that CPT clearly states that you should code for administration if an immunization is all you are doing (using CPT 99211 ); and the other is that, even if you are not getting reimbursed for vaccines because they were no cost to your practice, you must get those immunization codes in the record so it is documented that you have given the shots.

If were billing for the immunization itself, we bill the appropriate CPT code, says Barbara Hoag, billing supervisor for Pediatric Healthcare Associates, an 18-pediatrician practice in Trumbull, CT , a universal state. And, if its a state-supplied vaccine, we can charge a 99211, which covers the administration fee.

The free vaccines come with an administration fee that is reimbursed by the insurance company or by Medicaid. In universal states, every free vaccine (which [...]