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Vaccine Coding for Patients 19 and Older

Vaccine Coding for Patients 19 and Older


Q: I have a question regarding billing for physician counseling on vaccinations in patients 19 years and older. There is a code that already exists for ages 0 to 18 years for physician counseling for vaccination. Does a similar code exist for patients 19 years and older? If not, could a physician use a code related to counseling about medication? If so, what code would that be? Our goal would be to be able to attach an RVU for physicians who counsel patients about vaccinations. This takes up physician time and is an important discussion to have, but in our new compensation model, it goes unreimbursed.

A: Good question. As you are aware, the vaccine administration codes 90460 and 90461 specify that they require counseling related to the vaccinations by the physician or other qualified healthcare professional for patients 0 through 18 years of age.

The "adult code" 90471 specifies neither age or mentions counseling in any way. Of note, the 2016 Medicare fee schedule pays the same for 90460, 90471, 90461, and 90472.

The parenthetical instructions that accompany these codes make it clear that if no counseling is provided, then the adult codes must be used. This is followed directly with a reference to "separate and significant" E&M services and the instruction that if performed, the appropriate E&M service code should also be reported in addition to the vaccine and toxoid administration codes.

The larger context of that last section was undoubtedly to allow for the management of medical problems or health maintenance in addition to the vaccine administration. However, the term separate and significant doesn't exclude a discussion related to the vaccines.

All procedure codes include that amount of discussion related to the procedure itself (or in this case specific vaccinations) normally included or deemed necessary to responsibly complete the procedure.

Separate and significant can easily be defined as a discussion or service that goes well beyond the normal conversation associated with a given procedure.

These days, with all the media discussion of vaccines and autism and other conditions, it is not surprising at all that there would be separate and significant discussion about the advisability or risk related to given vaccines well above the normal amount of discussion that could be considered included in a vaccine administration relative value.


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