Pediatric Coding Alert

Change coding when intranasal, oral admin occur.

When your pediatrician orders vaccinations for a patient, there are a lot of details to keep straight in order to maximize rightful reimbursement.

One of those details is reporting the proper vaccine administration code. If you whiff on this code, the rest of your vaccination claim will likely strike out.

Help’s here: We’ve accumulated some expert input on these three tips to guide you through reporting vaccine administration codes, so you can code correctly each time your pediatrician orders vaccines.

Check Notes for Vaccine Admin Route

Remember that pediatricians seldom, if ever, administer a vaccine. This advice pertains to a pediatrician who orders vaccinations.

Code choice could be affected by route of administration when your physician orders a vaccine. For instance, the route of administration helps distinguish among the following four codes for administration of a vaccine(s):

• 90471, Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]
• +90472, …each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) as an add-on code to 90471
• 90473, Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
• +90474, …each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) as an add-on code to 90473.

Remember to use these codes for all patients under the age of 19. You can also use this set of codes to report vaccine(s) administration for a patient that is 18 or younger, if your physician or other qualified health care professional did not counsel either the patient or the patient’s parents about the vaccine.

When your clinician orders a vaccine intramuscularly, you need to report the first vaccine administration with 90471. If he orders more than one vaccine intramuscularly, you will need to report one unit of 90471 for one vaccine, and report appropriate units of +90472 for each of the other vaccines administered that are intramuscular, subcutaneous, or intradermal.

For instance, if your clinician orders three separate vaccines that are all intramuscular, you will need to report one unit of 90471 and two units of +90472.

Similarly, you report a vaccine administered orally or intranasally with 90473. If your clinician orders more than one vaccine through this route, you report the additional vaccines with +90474.

On the other hand, if your clinician orders one vaccine intramuscularly and the other vaccine(s) intranasally or orally, you cannot report 90473 with 90471. If you look at Correct Coding Initiative (CCI) edits, you will see that these two codes are bundled with the modifier indicator “0,” telling you that you cannot overcome the edit under any circumstance. In such an instance, you will need to report the vaccine administered intramuscularly with the base code, 90471 and the vaccine(s) administered orally or intranasally with appropriate units of +90474.

“Second, third, etc., vaccine administrations are always assigned the add-on codes appropriate for the route of administration,” confirms Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Tip 2: Opt for Different Codes for Some Younger Patients

When your pediatrician orders a vaccine for a patient who is 18 years or younger and during the encounter, he also counsels either the patient or the patient’s parents about the vaccine, you should not report any of the codes from 90471-+90474. Instead, you will need to report the administration of the vaccine with one of these codes, depending on encounter specifics:

• 90460, Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
• +90461, …each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure).

When you are using this set of codes, you report the same codes irrespective of route of administration. “The administration code is 90460 and +90461 that can be used for immunizations and vaccines when it includes a counseling component,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med, a medical auditing, coding and education organization in Pittsburgh, Pa.

If your provider orders a single-component vaccine with counseling to a patient 18 years or younger, report the vaccine administration with 90460. If your clinician is ordering two single-component vaccines to a patient along with counseling about each of the vaccines, you will need to report one unit of 90460 and one unit of +90461 for the administration of the vaccines.

“The descriptor of 90460 includes the phrase ‘first or only,’ so any component administered with counseling beyond the first will require the use of +90461,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Similarly, if your clinician orders a combination vaccine that provides coverage for different conditions and counsels on each component, you report one unit of the base code, 90460 for the first component of the vaccine or the first piece of the vaccine that controls a disease and report appropriate units of add-on code, +90461, depending on the number of components the combination vaccine has.

For instance, if the combination vaccine administered provides coverage for three different conditions, you report one unit of 90460 and two units of +90461.