Reporting vaccine administration can be tricky. Practices should review most recent updates and be aware of differences between commercial and federal payers.
Reporting vaccine administration can be tricky because there are different codes for Medicare and commercial plan patients. Most practices have mastered the changes made in 2011: But practices should remember to report additional units for additional components of each vaccine; be sure the correct serum code is reported if the practice buys the vaccine; and report only the administration if the patient or state provides vaccine serum to the patient.
The vaccine administration codes are defined by the route of administration, the number of components in the vaccine, and for patients 18 and younger, whether the clinician counseled the patient and/or family. The administration codes also encompass delivery of vaccines with multiple antigens. The route of the administration could be intramuscular, oral, or intranasal. These vaccine codes are in the 90460 to 90474 series of CPT codes.
CMS uses HCPCS codes for the administration of immunizations that it covers. These are reported in addition to the vaccine itself, if the practice purchases the vaccine. If the vaccine is supplied by the state or patient, do not report a charge for the serum. Some practices post the serum code with a .01 charge.
Vaccine administration with counseling
Practices should use 90460 and 90461 when a physician or other qualified health professional provides vaccine-related counseling to a patient and/or family member. Use these codes for patients from birth to age 18. Clinicians may be surprised to know that the payment for the administration codes with counseling is usually no different than the payment for the administration codes without counseling. 90471 and90472 are used for immunization administration by percutaneous, intradermal, subcutaneous, or intramuscular injections. 90471 is for the first component and 90472 is for each additional component. 90473 and 90474 are used for oral or intranasal administration.
Vaccines with multiple components
For vaccines with multiple components, report first the initial vaccination code and then report the add-on code for each additional component of the vaccine.
For example, parents bring their first child who is two months old to the physician's office for a well-child check. The physician explains the schedule and the rationale. The parents are concerned about immunizations and the doctor spends time counseling them about the importance of receiving immunizations on the recommended schedule. The baby receives a DTaP immunization. The practice should report 90460 once and 90461, two units, because the physician provided counseling and there were three components to the vaccine.
In July 2005 the CPT Assistant published an article about vaccine administration, when the only service provided was the administration. For a patient who returns for a vaccine and is seen only by the nurse, report only the vaccine administration. Do not report a nurse visit in addition.
Medicare vaccine coverage
Medicare covers very few vaccines on a routine basis. It is easy to find a list of those in chart form, and practices should download a new chart each year.
• Flu vaccine. CMS covers the flu vaccine and the administration of the vaccine for Medicare patients annually. Use G0008 for the administration of the vaccine. There are over a dozen flu vaccine codes for the serum itself, and these are found in the CPT book. Report the correct vaccine that is given to the patient, which is purchased by the practice.
• Pneumococcal vaccine. Medicare also covers the pneumococcal vaccine. Report the administration with code G0009, and one of the three CPT codes for the vaccine.
• Hepatitis B vaccine. Hepatitis B is covered for patients who are at intermediate to high risk of the disease. This includes healthcare workers who have contact with blood or body fluids during their work; patients with end stage renal disease; patients who live in the same household as a hepatitis B virus carrier; and patients with diabetes. Some other patients may be eligible, as well.
• Herpes Zoster vaccine. For Medicare, the herpes zoster vaccine is part of the drug benefit for some beneficiaries. It is not covered by Part B.
Betsy Nicoletti is the cofounder of Codapedia.com. She is the author of “A Field Guide to Physician Coding.” She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at firstname.lastname@example.org or 802 885 5641.