Pediatric Coding Alert

There is rampant confusion about what diagnosis codes to use when you administer vaccines. Should you use V20.2 (routine infant or child health check, including immunizations appropriate for age)? Or the specific ICD-9 codes which go with each vaccine (such as V06.4 for MMR)? Or V05.8 (need for other prophylactic vaccination and inoculation against single diseases; other specified disease) and V06.8 (need for prophylactic vaccination and inoculation against combinations of diseases; other combinations)?

While most pediatricians we have spoken to are using V20.2 and getting reimbursed for it, some are using the specific vaccine codes and getting reimbursed as well. So why does it matter which you use?

Avoiding Missed Opportunities

You should use the specific vaccine codes because using V20.2 implies that the child has to be well to get immunized, says Charles Schulte, MD, FAAP, the American Academy of Pediatrics representative on the AMAs CPT coding committee. We are trying not to have missed opportunities in immunizations, says Schulte, who practices at Countryside Pediatrics in Sterling, VA. If a child comes in for a check-up, and has otitis, the vaccinations should still be given, says Schulte. The otitis is not a reason not to vaccinate.

You should still use V20.2 for the well visit (99381-99385, 99391-99395), says Schulte, but you should use the individual vaccine codes for the immunizations. Also, be sure to utilize the vaccine administration codes (90471 for one, 90472 for two or more). This is true whether the child has a problem like otitis or not, he says. We are making an effort to get pediatricians not to use V20.2 for immunizations, says Schulte.

Here are some examples of how you should code immunizations, under different scenarios in boxes 21 and 24 of the HCFA 1500 form.

EXAMPLE 1

Preventive care services for 6 months, established patient: 99391 (diagnosis code routine infant or child health check), with DTaP (90700), Hib (90645, 90648, or 90647, depending on what youre giving), oral polio vaccine (90712), and Hepatitis B (90744 or 90745). Note that you must use the V06.8 (other combinations) for DTaP because there is no specific ICD-9 code for that combination, and V05.8 (other specified disease) for Hib because it doesnt have a specific ICD-9 code either. Polio vaccines get a diagnosis code of V04.0. Note that you should also use 90472, for administration of two or more vaccines.

In box 21, there are four slots for diagnosis codes. It doesnt matter what order you put the diagnosis codes in: Your reimbursement wont be affected in terms of this box. In this case, you are using five diagnoses. So to follow Schultes suggestion, you would have to print two different HCFA 1500 forms, using the fifth diagnosis on the second form.

FORM 1500: FIRST FORM, BOX 21:

		1. V05.3		2. V05.8
		3. V06.8		4. V20.2

SECOND FORM, BOX 21:

                     1. V04.0

Then, in box 24, you must fill out two columns, tying in the diagnosis codes to the appropriate procedure. For this example, box 24 should look like this:

FIRST FORM, BOX 24:

 		 D	          E
  
		99391	          4
		90700 	          3 
		90645                2 
		90744                1
		90472                1, 2, 3

SECOND FORM, BOX 24:

 		D	          E

		90712	          1

EXAMPLE 2

Office visit for 13 months, established patient, appointment for oral thrush: Code office visit as 99212, diagnosis code 112.0. The child missed her one-year checkup and is behind on immunizations, so the pediatrician wants to vaccinate today, instead of risking the patient not returning for a well visit in the next few months and missing the shots altogether. Vaccinations to be given are Hib (90645, 90648, or 90647, V05.8), MMR (90707, V06.4), oral polio vaccine (90712, V04.0), and varicella (90716, V05.4). Again, you will use vaccine administration code (90472) since you are giving two or more vaccines. Note that in this example, you have no V20.2, because you are not providing an entire well visit the parent didnt schedule one. Again, remember it doesnt matter in what order you list your diagnosis codes in box 21. Its only where you put them in box 24, as indicated by the numbers, which could affect reimbursement.

FIRST FORM, BOX 21:

		

		1.V05.8		2.V06.4
		3.V04.0		4.V05.4

SECOND FORM, BOX 21:

 	           1. 112.0 

FIRST FORM, BOX 24:

		D	          E
     
		90645	          1
		90707	          2
		90712	          3
		90716	          4
		90472	          1, 2, 3, 4

SECOND FORM, BOX 24:

		D	          E
     
		99212	          1

EXAMPLE 3

This is the same as Example 2, except that the pediatrician, at the request of the parent, went ahead and did a complete physical, even though the parent hadnt scheduled one. In this case, you would code 99392, assuming the child is an established patient, and use the V20.2 diagnosis code for that CPT code. You would also append modifier -25 to the 99212 (for the thrush) because you are using two E/M services codes on the same day.

FIRST FORM, BOX 21:

		1.V05.8		2.V06.4
		3.V04.0		4.V05.4

SECOND FORM, BOX 21:

		1.112.0
		2.V20.2

FIRST FORM, BOX 24:

		D	          E 
    
		90648	          1
		90707	          2
		90712	          3
		90716	          4
		90472	          1, 2, 3, 4

SECOND FORM, BOX 24:

		D	          E
     
		99212-25	          1
		99392	          2

Note that Example 3 would also apply to this case if the patient came in for a scheduled well visit at 1 year, got the required immunizations, and also had teething problems.

Benefits of V20.2

The goal of getting every child immunized is laudable, but be prepared for a possibly harried biller if you use this method. Using each diagnosis code for each vaccine is extremely cumbersome because the HCFA 1500 claim form only allows four diagnoses. Pediatricians may well give four vaccines at once, and then if you also have to use a diagnosis code for a well or sick visit or both you will find you are juggling diagnoses between forms in order to get everything to fit. It is easy to see why coders prefer to use V20.2 down the line. And if you know they will be paid this way, you can indeed use it, says Thomas Kent, CMM, president of Kent Medical Management of Dunkirk, MD, You have a choice, he says. Kent adds that on some computer systems, if you submit the claim electronically its a moot point anyway. Thats because each CPT code is treated individually, so theres no limit on the number of codes per date of service. If an insurance plan does not pay with the V20.0, then use the specific codes, recommends Kent. However, when the vaccine is given alone or in conjunction with an office visit, then you must use the individual vaccine diagnoses codes.