Pediatric Coding Alert

4 reasons to assign a specific ICD-9 code for each immunization

Should you save yourself some time and report V20.2 for all vaccinations? ICD-9 and coding experts say no. Here's why:

You may be tempted to use V20.2 (Health supervision of infant or child; routine infant or child health check) across the board. But, using the specific code correctly informs the insurer why you performed the procedure. "That's why we use the specific vaccine code rather than attaching V20.2 to the vaccines," says Teri Salus, health policy specialist for the American Academy of Pediatrics (AAP) division of healthcare finance and practice.

Example: You give a 2-month-old baby her first of three hemophilus influenza B vaccine (Hib) shots. You should link V03.81 (Other specified vaccinations against single bacterial diseases; hemophilus influenza, type B [Hib]) to 90647 (Hemophilus influenza B vaccine [Hib], PRP-OMP conjugate [3-dose schedule], for intramuscular use).

Code V03.81 tells the payer that you inoculated the child against Hib. If you use V20.2 instead of V03.81, you are incorrectly reporting that you performed a "routine infant or health check" rather than administering a Hib shot.

Taking the time to link each ICD-9 code to the appropriate immunization code will benefit your practice financially. You'll have better tracking, which may alert you to potentially costly coding mistakes, says Albert Jacobsen, MD, CPA, in "Strategies to Optimize Reimbursement for Pediatric Vaccinations."

For instance, billing tetanus-diphtheria (90718, Tetanus and diphtheria toxoids [Td] absorbed for use in individuals seven years or older, for intramuscular use) instead of varicella (90716, Varicella virus vaccine, live, for subcutaneous use) can cost you almost $48. (The difference is based on Medicare's 2004 drug allowable rates, which give $10.31 to 90718 and $57.86 to 90716.) Since the vaccines appear alphabetically on the superbill and the numbers are similar, you may easily interchange the procedure codes. But, if you see the varicella diagnosis (V05.4, Need for other prophylactic vaccination and inoculation against single diseases; varicella) linked to Td (90718), you can easily check the patient's age to determine which vaccine the child received.

Cross-referencing the diagnosis with the procedure code will also avoid missing vaccines.

Here's how: Suppose you have three vaccine diagnoses but only two vaccine procedures listed. You can see which procedure you omitted and add the potentially missed code.

Reserving V20.2 for well visits will help you avoid losing preventive exam payment. Many payers restrict the number of well visits a child may have, says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif. "If you use V20.2 for immunizations, you may max out the child's well benefits."

Why: Assigning V20.2 may trigger the insurer to apply well-care maximum benefits to the immunizations. The payer's system may use the preventive exam diagnosis (V20.2) to count the number of well visits (99381-99397, Preventive medicine services). Therefore, the vaccine uses one of the child's preventive visits and makes the vaccine code subject to the patient's deductible. Actually, the insurer shouldn't apply any limitations to the vaccines and should pay them at 100 percent.

You may hesitate to use individual ICD-9 codes because doing so creates a long claim. Payers only include five lines for reporting procedures, Jacobsen says. So, if you have a claim for a 15-month-old who comes in for a well check and is behind on immunizations, you could have seven codes.

In this case, you may be tempted to revert to billing +90472 (Immunization administration ...) per units. You'd use one unit for each vaccine administration. But, billing based on units won't allow you to match the correct ICD-9 code to the procedure, Jackson says.

Better way: Set up your computer system to start a separate ticket with 90472. That way, the payer won't deny stand-alone vaccine codes, Jackson says. "We've had no denials with this method." Make sure you link the appropriate vaccination diagnosis to each administration and immunization code.

Correct claim: You should code well visits with immunizations based on the following example: A15-month-old infant has a preventative medicine exam, and you give the measles, mumps and rubella (MMR) and diphtheria, tetanus toxoids, acellular pertussis, and Hib (DtaP-Hib) vaccines.