Pediatric Coding Alert

Question: The February 2007 Pediatric Coding Alert "You Be the Coder: Commit This Administration Rule to Memory" instructs not coding the pair 90465 and 90467. Why can I not report these codes together? Code 90465 is for an injectable, and 90467 is for an inhaled or oral vaccine. And if this edit is correct, does one administration route take precedence?

Answer: The advice on not reporting 90465 (Immunization administration younger than age 8 years [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels the patient/family; first administration [single or combination vaccine/toxoid], per day) and 90467 (Immunization administration younger than age 8 years [includes intranasal or oral routes of administration] when the physician counsels the patient/family; first administration [single or combination vaccine/toxoid], per day) on the same claim stems from CPT. "Do not report 90467 in conjunction with 90465," according to the parenthetical instruction following 90465 in the CPT 2007 Manual.

Rule 1: You should report only one "first" administration code during a single patient encounter. For instance, to report administration of two injectables to a patient younger than 8 years of age following physician counseling, you should report 90465 and +90466 (... each additional injection [single or combination vaccine/toxoid], per day [list separately in addition to code for primary procedure]).

Without physician counseling, the correct codes would be 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intra-muscular injections]; one vaccine [single or combination vaccine/toxoid]) and +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]).

For administration of two intranasal or oral vaccines, appropriate coding would be 90467 and 90468 -- or without physician counseling or patient age 8 years or older: 90473 (Immunization administration by intranasal or oral route; one vaccine [single or combination vaccine/toxoid]) and +90474 (....each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]).

Rule 2: Apply the same guidelines across route families. So if staff administers an injectable and an oral vaccine (such as Rotateq), you should report with physician counseling 90465 and 90468. Here you are using one code from the "first" administration family, 90465, and one code from the "each additional" family, 90468.

Rule 3: For payment reasons, code the injection administration first. Although no guidelines state that an administration route takes precedence as the primary code to report, the first injection code (90465) has a higher relative value unit (payment) than the first intranasal/oral code (90467). Technically, you could code the oral first (90467) and the injectable second (90466).

If you administer Rotateq alone as described in "You Be the Coder: Commit This Administration Rule to Memory," the code you will typically use is 90467. Reason: The AAP recommends that all three doses of the rotavirus vaccine (manufactured as Rotateq) be administered by 32 weeks of age, and pediatricians typically provide counseling at these visits as the scenario that you mention involved. If counseling and age requirements are not met, you would use 90473. See the AAP statement "Pentavalent Rotavirus Vaccine Implementation for 2006" at www.cispimmunize.org/pro/pdf/RotaVaccineImplementation2006.pdf.

Rule 4: You can mix counseling and noncounseling immunization administration codes. Using codes from both code families 90465-90468 and 90471-90474 during a single patient encounter "would be an uncommon event," notes the AAP in its answers to FAQs on immunization administration codes. Although CPT does not exclude this combination of codes, coding edit software programs including the NCCI edits developed by CMS may disallow reporting these coding pairs. For further information, see "Comprehensive Overview: Immunization Administration" at www.pcc.com/pub/pm/docs/AAP-immsadmin.pdf.