Pediatric Coding Alert

Question: At an 18-month preventive medicine service, the pediatrician noted that the toddler had missed one of her three scheduled DTaP shots. Today, the mother brought the toddler, who has a history of bronchiolitis, in for a flu shot and the catch-up injection. The mother told the nurse that the child was fine and that she had already been counseled on the vaccine and had no concerns. The nurse reviewed the vaccine history, presented the VIS, and received the physician's order for the Fluzone and DAPTACEL. She then administered and documented the vaccines. Should I report an E/M service in addition to the immunization administration?


North Carolina Subscriber


Answer: No. The nurse provided a service that was only vaccine-related and did not provide a significant or separate E/M service. Therefore, you should report only the immunization administration and the vaccine product code.

Because this is not a preventive medicine service, you should use the V code specific for the vaccine given, instead of V20.2 (Routine infant or child health check). Using V20.2 at a catch-up-only encounter could incorrectly count toward the child's annual allotted preventive medicine services.