Pediatric Coding Alert

There is rampant confusion about what diagnosis codes to use when you administer vaccines. Should you use V20.2 (routine infant or child health check, including immunizations appropriate for age)? Or the specific ICD-9 codes which go with each vaccine (such as V06.4 for MMR)? Or V05.8 (need for other prophylactic vaccination and inoculation against single diseases; other specified disease) and V06.8 (need for prophylactic vaccination and inoculation against combinations of diseases; other combinations)?

While most pediatricians we have spoken to are using V20.2 and getting reimbursed for it, some are using the specific vaccine codes and getting reimbursed as well. So why does it matter which you use?

Avoiding Missed Opportunities

You should use the specific vaccine codes because using V20.2 implies that the child has to be well to get immunized, says Charles Schulte, MD, FAAP, the American Academy of Pediatrics representative on the AMAs CPT coding committee. We are trying not to have missed opportunities in immunizations, says Schulte, who practices at Countryside Pediatrics in Sterling, VA. If a child comes in for a check-up, and has otitis, the vaccinations should still be given, says Schulte. The otitis is not a reason not to vaccinate.

You should still use V20.2 for the well visit (99381-99385, 99391-99395), says Schulte, but you should use the individual vaccine codes for the immunizations. Also, be sure to utilize the vaccine administration codes (90471 for one, 90472 for two or more). This is true whether the child has a problem like otitis or not, he says. We are making an effort to get pediatricians not to use V20.2 for immunizations, says Schulte.

Here are some examples of how you should code immunizations, under different scenarios in boxes 21 and 24 of the HCFA 1500 form.

EXAMPLE 1

Preventive care services for 6 months, established patient: 99391 (diagnosis code routine infant or child health check), with DTaP (90700), Hib (90645, 90648, or 90647, depending on what youre giving), oral polio vaccine (90712), and Hepatitis B (90744 or 90745). Note that you must use the V06.8 (other combinations) for DTaP because there is no specific ICD-9 code for that combination, and V05.8 (other specified disease) for Hib because it doesnt have a specific ICD-9 code either. Polio vaccines get a diagnosis code of V04.0. Note that you should also use 90472, for administration of two or more vaccines.

In box 21, there are four slots for diagnosis codes. It doesnt matter what order you put the diagnosis codes in: Your reimbursement wont be affected in terms of this box. In this case, you are using five diagnoses. So to follow Schultes suggestion, you would have to print two different HCFA 1500 forms, using the fifth diagnosis on the second form. [...]