Wiki Gardasil Vaccination Counseling 99401

[hswift]

We currently provide Gardasil for our patients. We bill 90471 for the immunization, 90649 for the vaccine. We have been billing 99401 with the first vaccination for the counseling session. Is this correct? What specific documentation should the MD's make regarding the couseling in their notes?
Thanks

 

[cedwards]

If the 99401 is a counseling code (I don't have my CPT book with me) I agree with the way you are billing the first vaccine with the counseling. The only documentation you need is to have the provider state that they counseled the patient on the risks, benefits, etc of the vaccine and gave a VIS. A simple statement in the chart such as I counseled that patient on XYZ is sufficient.