Pediatric Coding Alert

Know patient age, dose schedule for precision immunization coding.

Since 2006, the prevalence of human papillomavirus (HPV) among adolescents in the US has decreased significantly, particularly among females in the 14 through19 age group (Source: www.cdc.gov/std/stats17/adolescents.htm). This decrease in the incidence of HPV is mostly due to the Centers for Disease Control and Prevention (CDC)’s recommendation, beginning in 2006, to routinely vaccinate females between the ages of 11 and 12 and, since 2011, males in the same age group.

Even so, HPV remains the most common sexually transmitted infection (STI) in the country; worse, the virus can lead to more serious conditions, including genital warts, dysplasia, and cervical cancer (Source: www.cdc.gov/std/stats17/other.htm).

Because of that, we prepared this case study for you to refresh your knowledge of HPV vaccination and treatment.

Case Study

Your provider counsels a 14-year-old female patient who is not yet sexually active and who has yet to be infected by HPV. The pediatrician counsels the patient about the infection and the benefits of immunization, explains information contained on a Vaccine Information Statement (VIS) downloaded from the CDC (Source: www.cdc.gov/vaccines/hcp/vis/index.html), and answers any questions the patient asks. The patient/caregiver then agrees to be immunized, and your pediatrician administers the first dose.

First, Know Which Patients Can Be Immunized

“Young women can get the HPV vaccine until they are 27 years old and young men can get it until they are 22 years old,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. Additionally, “young men who have sex with other men or who have weakened immune systems can also get the HPV vaccine until they are 27,” Holle offers as a reminder.

Second, Code the Counseling

“If the patient only came in for discussion about the HPV vaccine, then you would report the preventive counseling codes based on time,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB,  owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin. This means you would pick from the following codes:

• 99401 — Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
• 99402 — ... approximately 30 minutes
• 99403 — ... approximately 45 minutes
• 99404 — ... approximately 60 minutes.

Coding caution: You will only use these codes if your pediatrician provides counseling to the patient and does not immunize the patient in the same session. You would code patient encounters that incorporate both counseling and immunization with 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).

Third, Code the Immunization

Whether the patient agrees to be immunized during or after the counseling session, once the patient is vaccinated, you will use one of three CPT^® codes designated for HPV vaccines:

• 90649 — Human Papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV), 3 dose schedule, for intramuscular use
• 90650 — Human Papillomavirus vaccine, types 16, 18, bivalent (2vHPV), 3 dose schedule, for intramuscular use
• 90651 — Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use.

“All of these vaccines are indicated for females and males aged 9 through 26,” Holle reminds coders. “Both Gardasil [90649] and Cervarix [90650] require a three-dose schedule, while your provider should administer two to three doses of Gardasil 9 [90651]. Due to your patient’s age, your provider should follow CDC recommendations: a two-dose schedule for girls and boys who initiate the vaccination series at ages 9 through 14 years. If your patient had been a year older through to the age of 26, or had been immunocompromised, CDC guidelines recommend that your provider administer a three-dose schedule (Source: www.cdc.gov/mmwr/volumes/65/wr/mm6549a5.htm).

As for the frequency of the immunizations, “for a two-dose schedule, the second dose should be given six to 12 months after the first dose,” says Rasmussen. “If the patient receives the second dose less than five months after the first, then she will require a third dose. The recommended three-dose schedule is zero, one to two, and six months,” Rasmussen adds.

“As for which is most appropriate, that is a clinical decision made by the physician and patient,” Rasmussen warns coders. However, no matter which your provider chooses, “all provide protection against HPV types 16 and 18, which are the two types believed to be responsible for about 70 percent of cervical cancer cases, while both forms of Gardasil protect against types 6 and 11, which cause 90 percent of genital wart cases,” says Holle.

Don’t forget: You would add 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)) for the vaccine administration if your pediatrician administered the immunization in a patient encounter that did not include HPV and HPV vaccine counseling.