Reporting Administration Codes with Vaccines

December 29th, 2015 - Allison Singer, CPC
Categories:   Coding   CPT® Coding   Diagnosis Coding   Modifiers  
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When it comes to billing for vaccines, the rules for reporting administration codes can be tricky. Reporting the right vaccine code alone is not enough to guarantee proper billing. Most billing scenarios allow providers to charge for both the vaccine product and the administration of the vaccine itself. However, there are a few exceptions in which the vaccine may not be billed, but the administration code may be reported. Coders must understand how to apply vaccine administration codes properly in order to ensure full reimbursement for these services.

 Administration Code Sets

There are three code sets that can be used to report vaccine administration codes:

  • 90465-90468 – Used when the physician provides face-to-face counseling to the patient        and/or family for patients younger than 8 years old
  • 90470-90474 – Used when there is no face-to-face counseling for patients of any age
  • HCPCS G-codes – Used on a limited number of vaccines, based on carrier (e.g.  Medicare)

Note: G-codes follow different reporting guidelines than the CPT® administration codes (90465-90474). See the section HCPCS Administration Codes on page 3 of this article for specific HCPCS administration code rules.

Route of Administration

To select the appropriate administration code, you must first know the route of administration of the vaccine itself. Most vaccines are given as injections, such as percutaneous, intradermal, subcutaneous or intramuscular. However, there are also a few oral and intranasal vaccines (90476, 90477, 90660, 90680, 90681, 90690 and 90712).

Initial Vaccines

If one or more vaccines are performed during an encounter, an initial administration code must be reported. The initial administration codes include:

  • 90470 – tracks the H1N1 vaccine (intramuscular or intranasal) and includes counseling 
  • 90465 or 90471 – tracks injectable vaccines (for example, percutaneous, intradermal,             subcutaneous or intramuscular)
  • 90467 or 90473 – tracks oral or intranasal vaccines

 When more than one vaccine is given during the same visit, coders must decide which initial administration code to use. Refer to the following guidelines:

  • Report only one initial administration code per claim.
  • If the H1N1 vaccine is given, report 90470 as the initial administration code.
  • Report counseling administration codes (90465-90468) before non-counseling administration codes (90471-90474).
  • Report administration codes for injectable vaccines (90465-90466, 90470-90472) before oral or intranasal vaccines (90467-90468, 90473-90474).

Subsequent Vaccines

If more than one vaccine is administered on the same day, a second or third administration fee is required to document the additional vaccines. All subsequent vaccine codes are classified as add-on codes and must never be reported without an initial administration code (90465, 90467, 90470, 90471 or 90473). The definitions for the subsequent administration codes are as follows:     

  • 90466 or 90472 – track injectable vaccines
  • 90468 or 90474 – track oral or intranasal vaccines

Apply units to the subsequent administration code for every additional vaccine (two or more) of the same type (injectable or oral).

Note: The total number of units for the initial and subsequent administration codes should equal the total number of vaccines given. Refer to the following examples: 

2 Injectable Vaccines with Counseling

  • 90465 x1 unit (Initial)
  • 90466 x1 unit (Subsequent)             

5 Injectable Vaccines

  • 90471 x1 unit (Initial)         
  • 90472 x4 units (Subsequent)          

1 Intranasal, 2 Oral Vaccines           

  • 90473 x1 unit (Initial)
  • 90474 x2 units (Subsequent)

Remember to report injectable administration codes before oral or intranasal administration codes. Refer to the following examples:

1 Injectable Vaccine with Counseling, 1 Oral Vaccine                            

  • 90465 x1 unit (Initial)                                           
  • 90468 x1 unit (Subsequent) 

4 Injectable Vaccines, 1 Oral Vaccine              

  • 90471 x1 unit (Initial)
  • 90474 x1 unit  (Subsequent)
  • 90472 x3 units (Subsequent)

Table 1 includes a quick reference for valid and invalid administration code combinations. Cells with NA represent invalid code combinations, and blank cells represent valid combinations.  

 

Code

90465

90466

90467

90468

90470

90471

90472

90473

90474

90465
NA
 
NA
 
NA
NA
 
NA
 
90466
 
NA
NA
 
 
NA
 
NA
 
90467
NA
NA
NA
 
NA
NA
NA
NA
NA
90468
 
 
 
NA
 
NA
 
NA
 
90470
NA
 
NA
 
NA
NA
 
NA
 
90471
NA
NA
NA
NA
NA
NA
 
NA
 
90472
 
 
NA
 
 
 
NA
NA
 
90473
NA
NA
NA
NA
NA
NA
NA
NA
 
90474
 
 
NA
 
 
 
 
 
NA

  HCPCS Administration Codes

When billing influenza, influenza H1N1, pneumonia or hepatitis B, the Centers for Medicare and Medicaid (CMS) require physicians to report HCPCS administration codes rather than CPT® administration codes. The HCPCS administration codes and the vaccine codes have a one-to-one relationship and are always paired together. Rules for reporting initial or subsequent vaccines do not apply. The HCPCS administration codes and the vaccines they are paired with are listed below:

  • G0008 - Influenza (90658) 
  • G0009 - Pneumonia (90732)
  • G0010 - Hepatitis B (90746)
  • G9141 - Flu H1N1 (G9142)

 If other vaccines are combined with these four G-codes, the standard CPT® administration codes (90465-90474) must be used to track the remaining vaccines. Listed below are examples of a Medicare claim and a non-Medicare claim:

Medicare       

  • 90658
  • G0008 (G-Code)
  • 90703
  • 90471 (Initial)
  • 90707
  • 90649
  • 90472 x2 units (Subsequent)
Non-Medicare
  • 90658
  • 90471 (Initial)
  • 90703
  • 90707
  • 90649
  • 90472 x3 units (Subsequent)

In the above Medicare example, there is a total of four vaccines, one HCPCS administration code (G0008), and two CPT administration codes (90471 and 90472)—three administration codes in all. In the non-Medicare example, there are still four  vaccines, but only two CPT® administration codes (90471 and 90472). Both scenarios are correct, depending on the payer.

Note: For Medicare, add modifier 59 to any CPT® administration code (90465-90474) if it is on the same claim as a HCPCS G-code. Check with other payers to see if they also require a modifier 59.

State Vaccine Programs or Vaccines for Children (VFC)

Physicians who participate in state Vaccines for Children (VFC) programs are provided with vaccines by the state. Therefore, physicians may not charge the beneficiaries for the vaccines, and are not separately reimbursed by Medicaid or commercial carriers. However, providers are allowed to charge for administering the vaccines (90465-90474). Depending on how you track the state-provided vaccines, you may need an SL or VFC modifier with the vaccine code (90476-90749). Check with your state VFC program and local carriers for specific rules.

 Age-Specific Vaccines

Certain vaccines specify age requirements. The definitions may indicate a date range, or they may be more generic and only state whether the patient was a pediatric patient or an adult. Make sure the patient demographics (that is, the patient’s age) and the vaccine requirements do not contradict one another. The age-specific vaccines include the following: 90632, 90633, 90634, 90636, 90655, 90656, 90657, 90658, 90669, 90696, 90700, 90702, 90714, 90715, 90718, 90732, 90743 and 90744.

Diagnosis

Each vaccine has a corresponding V-code listed in the ICD-9 manual (see V03 through V06.9). Sometimes V20.2 may be used as the diagnosis for vaccines, but most often, you should apply the specific V-code from V03 through V06.9.

Vaccines and Evalualtion and Management Codes

National Correct Coding Initiative (NCCI) edits do not allow 99211 to be billed with any vaccine administration codes (90465-90474). For separately billable evaluation and management (E/M) services performed on the same day as vaccines, add modifier 25 to the E/M code.

2010 Vaccine Updates

The American Medical Association recently released an announcement for 2010 vaccine updates. See the following link for more details: http://www.ama-assn.org/ama1/pub/upload/mm/362/vaccine-codes.pdf

Resources

2009-2010 Immunizers’ Question and Answer Guide to Medicare Coverage of Seasonal Influenza and Pneumococcal Vaccinations

http://www.cms.hhs.gov/AdultImmunizations/Downloads/0910QAGuide.pdf

Coding for Vaccines and Administration

http://www.aafp.org/online/en/home/practicemgt/codingresources/immunizations.html

Vaccination Management: Is Your Practice on Target?

http://www.medscape.com/viewarticle/584966 
 

 

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