Pediatric Coding Alert

Question: We're spending a lot of time counseling parents on the importance of receiving immunizations, contraindications, etc. Sometimes, after the parent has given permission for the immunizations and the nurse has prepped the supplies, the mom changes her mind. In these cases, can we still bill 90465 for the counseling with the reduced services modifier?

Ohio Subscriber

Answer: When using modifier 52 (Reduced services), you must not disturb the basic service's identification, according to the AMA's Coding With Modifiers by Deborah Grider, CPC-EMS, CPC-H, CPC-P, CCS-P, president of the American Academy of Professional Coders.

When you provide vaccine counseling without vaccine administration, you are not furnishing the basic service, immunization administration. Therefore, reporting 90465 (Immunization administration younger than 8 years of age [includes percutaneous, intradermal, subcutaneous, or intramuscular injections] when the physician counsels the patient/family; first injection [single or combination vaccine/toxoid], per day) even with modifier 52 is inappropriate.

If this is during a preventive medicine service (such as 99381, Initial comprehensive preventive medicine E/M service of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction/interventions, and the ordering of appropriate immunization[s] ... infant [age younger than 1 year]) and the documented physician vaccine counseling time without administration is extensive, you could use the preventive medicine counseling and/or risk factor reduction codes (99401-99404) linked to the vaccine refusal (V64.05, Caregiver refusal of vaccine).

You may need to use modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the preventive medicine service (for instance, 99381-25) in addition to 99401-99404. Make sure your documentation supports the reported counseling time, such as 15 minutes for 99401 (... approximately 15 minutes).

-- Answers to You Be the Coder and Reader Questions provided/reviewed by Suzan Hvizdash, CPC, CPC-E/M, CPC-EDS, medical auditor for University of Pittsburgh Physicians; Robin Linker, CPC, CPC-H, CCS-P, CPC-P, MCS-P, CHC, CEO of Robin Linker & Associates Inc. in Aurora, Colo.; and Richard H. Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.