Pediatric Coding Alert

Question: A pediatrician gives multiple vaccines during a visit. Do we include modifier 59 with +90472?

Georgia Subscriber

Answer: Whether you should append modifier 59 (Distinct procedural service) to +90472 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]) will depend on your payer's guidelines.

Technically, per CPT you should not need to use a modifier and payers should allow you to report additional vaccines by unit (+90472 x 2, for example). Payers that do not accept units may require you to report +90472 once, then distinguish additional vaccinations with +90472-59.

Don't miss: If the physician administered the injection, she probably also provided vaccine counseling during the visit. When that's the case, you should be using 90466 (Immunization administration younger than 8 years of age [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels the patient/family; each additional injection [single or combination vaccine/toxoid], per day [List separately in addition to code for primary procedure]) rather than +90472.

Note: Some insurance companies pay more for the immunization administration in individuals less than 8 years of age with physician vaccine counseling than the older patient/no physician vaccine counseling codes (90471-+90474).

Watch: Make sure you're also paying attention to the route of administration. Many payers have adopted fee schedules that include higher reimbursement for the initial injectable codes than for the initial inhalation codes. When you code for both types, always report the injectable vaccine as the first administration (either 90466 or 90471).