Wiki Vaccination refusal

[lisaneese]

We receive denials from payers if we code Z28.21. When are we supposed to pick up this code? Say, if the provider offers a influenza vaccine but the patient doesn't want it or has already received it, do you add it? What if the visit was not intended for the vaccination but it was offered and refused (say at a regular follow up visit)?

 

[CBLENNIE]

What are you coding as a procedure with Z28.21? If the patient has already had the disease is the vaccine, they are refusing for a vaccine that is only necessary once in a lifetime (or the series is only necessary once in a lifetime), or is something like COVID? If the patient has had the disease you may need to see if there is an appropriate "history of" DX that could/should be billed in this scenario.

Also, what exactly would your provider be doing that is a billable service if they offer a patient an influenza vaccine and the patient refuses for whatever reason? Are you just wanting to code the diagnosis that the vaccine was offered and declined or are you looking to get paid for the offering of the vaccine?

I feel like there is information missing about the claims that are being submitted w/Z28.21 and are being denied by the payers. What are the reason codes on the remit that explain the denial reason?

 

[lisaneese]

What are you coding as a procedure with Z28.21? If the patient has already had the disease is the vaccine, they are refusing for a vaccine that is only necessary once in a lifetime (or the series is only necessary once in a lifetime), or is something like COVID? If the patient has had the disease you may need to see if there is an appropriate "history of" DX that could/should be billed in this scenario.

Also, what exactly would your provider be doing that is a billable service if they offer a patient an influenza vaccine and the patient refuses for whatever reason? Are you just wanting to code the diagnosis that the vaccine was offered and declined or are you looking to get paid for the offering of the vaccine?

I feel like there is information missing about the claims that are being submitted w/Z28.21 and are being denied by the payers. What are the reason codes on the remit that explain the denial reason?

This scenario would be that the patient comes in for an office visit (say a follow up visit) and the provider offers a vaccination (say flu) and the patient doesn't want to take it (no specified reason). Do we code the Z28.21 simply because it was documented as offered and refused?

 

[CBLENNIE]

To be clear you are not charging the patient for a service related to the provider's offer of the vaccine, correct? You indicated in your original message that claims are receiving denials when you use DX Z28.21, so I'm confused on what you are submitting to the payer that they are denying.

• Are you listing this DX as the primary DX on the claim?
• Or are linking it to billed service in a second, third or fourth position on the claim line?

Can you provide some redacted examples of claims that you submitted with Z28.21 which were denied by the insurance company as well as what the denial reason was for the service?

FYI:
Per the ICD-10 Guidelines for Chapter 21 Factors Influencing Health Status and Contact with Health Services (Z00–Z99), Category 14-Miscellaneous Z codes states the following:

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So basically Z28.21 is an informational code that is optional and should not be used to bill for services, unless your state's Medicaid program has instructions to use this code for billing services.

Also, if your provider participates in some type of payer program which provides additional reimbursement or bonuses linked to their patient's health outcomes, you may need to report this code if there are specific metrics in the provider's contract related to the vaccination rates of the patients covered by the insurance company.

I work for an insurance company, and we do have certain programs surrounding increasing the vaccination rates of patients covered by our plans which will provide a bonus or increase the provider's contract allowances if they meet certain metrics. So, providers would want to submit claims with Z28.21 on them as an informational only code to indicate they offered the vaccine and the patient declined. The provider should receive credit for trying to improve their patient's vaccination rates and not lose out on the additional reimbursement due the patient's decision to decline the vaccine.