Coding for Vaccine Administration

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
February 21st, 2015

Information on Medicare Vaccine Coverage

Medicare Part B Vaccine Coverage

Medicare Part D Vaccine Coverage

Vaccine Coding

Vaccines Administered at Well-child Visits

When vaccines are provided as part of a well-child encounter, the ICD-9 guidelines instruct that code V20.2 (routine infant or child health check) includes immunizations appropriate to the patient's age. A code from categories V03-V06 may be used as a secondary code if the vaccine is given as part of a preventive health care service, such as a well-child visit.

ICD-9 for Combination Vaccines

When reporting ICD-9 codes for prophylactic vaccination and inoculation against combinations of diseases, use V06.0-V06.9. Report also single vaccination codes from V03-V05 for any vaccinations not included in the combination code.

Evaluation and Management Services Provided on the Same Date as Vaccine Administration

When an evaluation and management service (other than a preventive medicine service) is provided on the same date as a prophylactic immunization, modifier -25 may be appended to the code for the evaluation and management service to indicate that this service was significant and separately identifiable from the physician's work of the vaccine counseling/administration.

Example: A patient presents for a visit to evaluate the control of his/her diabetes and at the same visit receives an influenza vaccine administration. A physician might report code 99213-25 with diagnosis code 250.00 in addition to the appropriate flu vaccine and administration codes.

Adding National Drug Codes (NDC) to Claims

Medicaid plans and private payers may require the inclusion of a vaccine product's National Drug Code (NDC) on your claim line for each vaccine product. This can be a bit confusing if the product is labeled with a 10-digit NDC, as HIPAA requires that NDC have 11-digits. To correctly report the NDC in the HIPPA format, you may have to translate the NDC.

The common format for submitting an NDC is a number that, if hyphenated, would appear in a 5-4-2 format. Some drug products are labeled in 4-4-2, 5-3-2, or 5-4-1 formats. To change these codes to the 11-digit format, a zero is placed within the product code to create the 5-4-2 format.

Here are some examples showing addition of a zero to create this format:

10-digit NDC

11-digit NDC

4444-4444-22

04444-4444-22

55555-333-22

55555-0333-22

55555-4444-1

55555-4444-01

This information is not required by all payers.

Reporting Administration per Component

The pediatric immunization administration codes are:

These codes are reported per vaccine/toxoid component. CPT defines a component for these purposes as each antigen in a vaccine that prevents disease(s) caused by one organism. Combination vaccines are those vaccines that contain multiple vaccine components.

You may report multiple units of code 90460 for each first vaccine/toxoid component administered. No modifier should be required when reporting multiple first components. Note also that code 90460 does not apply only to combination vaccines, but also to single component vaccines (such as influenza, human papilloma virus, or pneumococcal conjugate vaccines). This base code is reported for each vaccine administration to patients 18 years of age and under who receive counseling about the vaccine from a physician or qualified health care professional at the time of administration. Code 90461 is an add-on code reported for each additional vaccine component administered.

Report codes 90471-90474 for immunization administration of any vaccine that is not accompanied by face-to-face physician or other qualified health care professional counseling the patient and/or family, or for patients over 18 years of age.

Items of Note About Codes 90460 and 90461

To correctly report vaccine counseling and administration with these codes, it is important to recognize what the codes do and do not include.

Administration Coding Example

An 11-year old girl presents for a preventive visit (99393). In addition, the child and her mother are counseled by the physician on risks and benefits of HPV (90649), Tdap (90715) and seasonal influenza (90660) vaccines. The mother signs consent to administration of these vaccines. A nurse prepares and administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is no immediate adverse reaction.

CPT Codes reported are:
99393 - Preventive service
90649 - HPV vaccine
90460 - Administration first component (1 unit)
90715 - Tdap vaccine
90460 - Administration first component (1 unit)
90461 - 2 additional components (2 units)
90660 - Influenza vaccine, live, for intranasal use
90460 - Administration first component (1 unit)

 

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Coding for Vaccine Administration. (2015, February 21). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/coding-for-vaccine-administration-2392.html

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