Vaccine Coding for Patients 19 and Older

June 27, 2016

How to institute vaccine administration codes for patients who are older than 19 years of age. Also, guidance on follow-up codes in electronic billing.


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.

So yes, in those instances where there is significant additional discussion and time spent, enough to either generate or support an additional E&M, or enough to maybe change the level of the E&M based on documented time - then you can say that this service would have a discreet value.

The CPT manual does not have a specific code for this. You'd have to use an E&M code. As above either in addition to the existing service, or in some way changing an E&M already being used.

The expectation would be a distinct section of the note pertaining to the conversation or counseling about the vaccination. Not a generic macro-like quick text tacked on to every vaccination encounter - but rather some detail about the specifics of that patient's concerns related to a given vaccine.

Were this to become a wholly standard add-on with computer-generated text - you'd in effect be changing the meaning and RVU of the 90471 code - no payer would appreciate that.

Your point is well taken though that this is a bit of provider work that may currently go unrecognized. As to the RVU question, you may wish to form a small group, or task someone with figuring out the variables in these scenarios to come up with some standard values. Unless you want to create internal codes, I'd let the E&M levels handle the variance in work.

You have to recognize that it is entirely possible that some of the vaccine specific times involved here could be short enough to fall within time variances for any given E&M code.


Q:We just switched to electronic billing, which has made it a much easier to remember patient acuity level and complexity of treatment plan on a day-to-day basis, since now I bill daily instead of weekly. However, before I start changing some of my 99231s to 99232s, I had a quick question. While I already know the level of documentation required for that code, is the moderate follow-up code simply based on complexity of medical decision making such as "med changes" or when medications/treatment plans stay the same, can it also be based on simple level of acuity, such as "still grossly psychotic and unable to care for self" or "still suicidal/homicidal," such as when I decide between moderate and high admission codes. I just wasn't entirely sure on the follow-up codes.

And just to clarify, if a patient remains grossly psychotic or suicidal, but I don't make any medication changes that day, can I still bill moderate? That would be considered acute illness right?

A: The medically necessary code is best predicated on decision making. For follow-up visits, although the guidelines say three out of three for history, physical examination, and medical decision making (A/P) - look to the medical decision making as you suggest.

A 99232 (moderate) is either three stable problems, one stable and one worsening, one new problem with uncertain prognosis, or acute illness with systemic symptoms.

Your mention of "med changes" and "still grossly psychotic and unable to care for self" imply those conditions - but make it clear so the regulators/auditors can count and word match when assessing the A/P.

This brings us to your second point. Your patient who "remains grossly psychotic or suicidal" could be moderate or high on the risk table (Table 3), but if these aren't new problems anymore they could drop all the way to a 99231, if it is the only problem.

*Facing a coding conundrum? We're here to help. Send your questions to coding expert Bill Dacey at He will help clear up the confusion.