Pediatric Coding Alert

Question:  Our pediatrician just saw a 7-year-old patient who was behind on his 6-year-old immunizations. We billed 90700, 90460, 90461, 90744, 90460, 90713, 90460, 90716, and 90460, but Empire Blue Cross/Blue Shield denied the claim, citing C07: The procedure/revenue code is inconsistent with the patient’s age. How should we have billed this?

Codify Subscriber

Answer: The denial does not come from billing 90744 (Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use), 90713 (Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use), and 90716 (Varicella virus vaccine (VAR), live, for subcutaneous use) along 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). None of these vaccines are age-specific, and your use of 90460 for the administration is appropriate given the patient’s age.

The problem stems from reporting 90700 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use) with 90460 and the add-on +90461 (… each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) for the three components. Your payer has denied this part of the claim because, per the CPT^® descriptor for 90700, the DTaP (diphtheria, tetanus, and pertussis) vaccine is for children younger than 7. Even though your patient is playing catch-up with the vaccination schedule, you cannot use the code as the patient is now over the age of 7.

The Centers for Disease Control (CDC) recommends that “persons aged 7–18 years not fully immunized with DTaP” receive“1 dose of Tdap as part of the catch-up series (preferably the first dose)” and that, “if additional doses are needed, use Td” (Source: www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html#f13).

This means your payer is following CDC guidelines and insisting that your patient should have been given the Tdap (Tetanus, diphtheria, and pertussis) vaccine instead of DTaP.

Tdap vaccinations are coded with 90715 (Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use) which, per the descriptor, is appropriate for patients older than 7.