Oncology & Hematology Coding Alert

One code isn’t enough and age of the patient matters.

Immunizations, which are seemingly simple, can throw ample challenges for coders. The coding challenges are further intensified by rules that vary from one payer to another. Here are answers to two common questions that can come your way when reporting immunizations.

Vaccines May Not Comprise Just One Code

Question 1: Do flu vaccines always require two codes?

Answer: Yes, you will need to report more than one code. In order to help ensure correct billing and payment, two codes are needed for each vaccination claim: one administrative code and one vaccine code. You’ll report a flu vaccine administration code (such as 90460-90474) and another code for the vaccine itself, such as 90630 (Influenza virus vaccine, quadrivalent [IIV4], split virus, preservative free, for intradermal use), 90653 (Influenza vaccine, inactivated [IIV], subunit, adjuvanted, for intramuscular use) or another appropriate code that describes the material injected.

Therefore, if you administer a flu shot that includes preservatives to a twelve-year-old child and the physician performs counseling, you’ll likely report 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) and 90658 (Influenza virus vaccine, trivalent [IIV3], split virus when administered to individuals 3 years of age and older, for intramuscular use). Use Z23 (Encounter for immunization) as the diagnosis code.

Coding Tip: Although the example refers to a flu shot, this rule is true of all vaccines—you should always bill an administration code as appropriate and the actual vaccine CPT^® code.

Check Age for HPV Vaccines

Question 2: Our physician administered a Gardasil vaccination to an eight year old patient and the claim was denied based on an age edit. Can you advise?

Answer: Most payers will only reimburse HPV vaccinations for patients ages nine through 26. The Aetna policy, for instance, states, “Aetna considers Gardasil, Gardasil 9, and Cervarix a medically necessary preventive service for girls and women age 9 to 26 years. Aetna considers Gardasil and Gardasil 9 a medically necessary preventive service for boys and men age 9 to 26 years.”

Therefore, if your patient is age nine or older, most insurers will reimburse you for the vaccination. Keep in mind, however, that you can’t typically collect for a Gardasil 9 vaccination if the patient has already completed a three-dose series with Gardasil or Cervarix.

For your HPV vaccine patients, you’ll report the appropriate administration code such as 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) or the 90460 for counseling administration codes, along with the vaccine code, such as 90649 (Human Papilloma vaccine, types 6, 11, 16, 18 ,quadrivalent [4vHPV], 3 dose schedule, for intramuscular use). You’ll use Z23 as the ICD-10 code.