Internal Medicine Coding Alert

Question: Our physician recently saw a 27-year-old patient who presented to our internal medicine practice for varicella vaccine. Our clinician took a brief medical history and family history. The patient had no other complaints. What codes do I report for the administration of the vaccine to this patient and for the medication? Also, should I report any E/M codes for this encounter and what diagnosis codes should I use?

Alabama Subscriber

Answer:

When a vaccine or many vaccines are administered to a patient above the age of 18 years, you will have to report from the code range, 90471-90474 depending on the number of vaccines administered and the route of administration.

Since your clinician only administered the varicella vaccine, you will have to report only 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) for the administration of the vaccine. If additional injections were provided in the same visit, you will have to report it with the appropriate add-on code depending on route of administration.

You will also need to report the CPT® code for the varicella vaccine separately. You will report this with 90716 (Varicella virus vaccine, live, for subcutaneous use).

If the patient had no other medical complaints (as is the case in the scenario described), you will not have to report any E/M code separately for the visit. The brief medical history taken by the doctor giving the injection was part of the care before giving varicella injection. So, no E/M can be billed.

However, if the vaccine was administered at the same visit as a problem-oriented (e.g., some other sickness) evaluation and management (E/M) service, the appropriate ICD-9-CM code is linked to the E/M service (99201–99215) and codes V03–V06 are linked to the vaccine/toxoid product and immunization administration codes.