vaccine counseling documentation

khristinelouise

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Can anyone tell me if this documentation is sufficient for billing 90460 imm admin w/ counseling?
HIB vaccine 90648 Counseling by: providers name MD
It doesn't seem sufficient to me but the people I work with feel it is.
 

JenniferB7

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This article might help: https://www.aapc.com/blog/12458-stick-to-the-facts-on-childhood-immunization-coding/

Pulling from the article:

Counseling by a physician or other qualified health care professional (e.g., physician assistant or nurse practitioner) at the time of the administration is critical and a requirement of 90460 and 90461. Let’s define counseling.

CPT® requires each service billed to be fully and independently supported by medical record documentation, but does not go into specific detail about exact requirements to support the counseling of each component. Providers must provide face-to-face counseling, and then choose the format that works for them and their clinic, while still making it crystal clear which vaccine components were counseled on, and what that entailed.

For example, a note might include all vaccine components recommended at this visit, a notation that each component had counseling, and any issues discussed specific to those patient risk factors.

The documentation should support the time and effort associated with administering combination vaccines. Photocopying a statement, stamping a statement, or cutting and pasting templated documentation should be avoided. If you are concerned about your specific templates or documentation format, check with your payers to see what their payment policies are surrounding these new codes.

Based on your example, you know the vaccine components counseling was provided for, but no details or summary as to what that counseling entailed. Counseling documentation usually requires a brief summary of what was discussed (i.e., risks/benefits, contraindications, patient questions were answered, risk factors, etc.). Pulling from counseling documentation for E/M services, if you are using face-to-face time counseling a patient to determine your E/M code, then according to the E/M guidelines, "the extent of counseling and/or coordination of care must be documented in the medical record." Just documenting that you counseled the patient for 20 minutes is not sufficient to code based on counseling time.

Here is an additional article that references the article above: http://advizehealth.com/vaccine-administration-counseling/

Hope that helps!

Jennifer M. Connell, CPC, CPCO, CPC-P, CPB, CPMA, CPPM, CPC-I, CENTC
 
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