Pediatric Coding Alert

Rule: Revert to 90471-90474 when encounter doesn't meet 90465-90468's age, counseling criteria

You can eliminate the confusion that CPT created with its addition of four new pediatric-specific immunization administration codes if you follow these steps.
 
1. Educate Staff

First, you should get the message out that four new vaccine administration codes exist. "Pediatricians are used to using 90471-90474," says Victoria S. Jackson, CEO of Southern Orange County Pediatric Association with 11 pediatric offices in California. Now you have four more codes to think about: 90465-90468.
 
Tip: To make sure you're reporting the right vaccine administration code, inform staff that they should sometimes consider 90465-90468. "Pediatricians are accustomed to circling 90471-90474 on a superbill," Jackson says. You should educate physicians that four additional codes may describe their service.
 
Problem: "[The new codes] are a little confusing," says Bonnie Palmer, billing manager at Tots N Teens Health Associates in Hoffman Estates, Ill. When should we report the new codes versus the old codes? she asks.
 
Key: You should use 90465-90468 when the service meets the codes' age and counseling criteria.

2. Check the Patient's Age

When a child receives a vaccine, you should look at his age. "If the child is under 8 years of age, you may be able to use the new vaccine administration codes," Jackson says. Codes 90465-90468 describe vaccine administration in the pediatric population.
 
Don't use 90465-90468 if the case surpasses the age requirement. If the patient is 8 years of age or older, "you should revert to the old codes" - 90471-90474 - says Linda Walsh, senior health policy analyst with the American Academy of Pediatrics (AAP) Division of Health Care Finance and Practice.
 
Caution: Just because a child meets the new codes' age criteria doesn't make the patient a shoe-in for 90465-90468. "The service must also include one additional item - counseling," Jackson says.

3. Consider Pediatrician's Role

To finally determine which vaccine-administration code set applies, you should look at what shot-related services the pediatrician provided. "If the pediatrician performs the counseling, you should use the new codes - 90465-90468," Jackson says.
 
Good news: Codes 90465-90468 involve nothing above and beyond normal vaccine administration counseling.
 
The physician counseling in these codes refers to what "pediatricians have been doing all along," Jackson says in The Coding Institute's teleconference "Pediatric Update 2005" on Dec. 15, 2004. "The AAP fought for the creation of these codes so that pediatricians could finally receive credit for the counseling service."
 
Some of the biggest confusion surrounding these new vaccine administration codes, however, still comes from the term "counseling." Here's what the counseling requirement involves:
 
"The physician must perform face-to-face vaccine counseling during that patient encounter," Walsh says. The pediatrician doesn't have to give the shot. "The nurse can be the one to actually administer the vaccine," Walsh says.
 
In addition, you may report 90465-90468 when a nurse practitioner or nonphysician practitioner does the counseling. "Advanced-practice nurses can report CPT services listed with specific reference to 'physician' in the code descriptor, as long as they are within their scope of practice by state licensure regulations," Walsh says.

Nurse May Give Shot Without MD Present

Scenario: During a 6-year-old's preventive medicine service, a pediatrician tells the parent about the vaccine product and possible reaction, and answers any questions. After the physician leaves the exam room, a nurse comes in. She has the parent sign the necessary paperwork and administers the vaccines. In this case, you should use the new vaccine administration codes (90465-90468).
 
Why: The scenario includes both of 90465-90468's requirements:

 1. The patient meets 90465-90468's age criteria - she is under 8 years of age.
 2. The pediatrician provides face-to-face vaccine counseling. Even though she doesn't give the shot, she performs 90465-90468's necessary counseling component. "The physician doesn't have to give the injection or be in the room to use the new codes," Jackson says.

Administration, Counseling Must Occur at Same Encounter

Warning: Don't use the new codes if you split the counseling and vaccine administration.
 
Suppose the child in the above well-check scenario doesn't receive the injections at the visit. The mother is worried that her daughter may be coming down with a cold, so she requests that the pediatrician delay the injections.
 
"In this situation, you should not report 90465-90468,"  Jackson says. You should use the new codes only when the counseling occurs on the same day as the administration, she says. If the pediatrician performs the counseling on a different day, revert to the old codes 90471-90474.