Pediatric Coding Alert

Keep your vaccine money flowing with these easy-to-implement tips.

Vaccine payments make up a significant part of your pediatric practice's A/R, but if you fall under the spell of these common myths, you could be losing your immunization income. Check out the following five vaccine coding pitfalls, and follow our advice to ensure that you don't fall into these traps.

Myth 1: You Should Always Report V20.2 With Vaccines

Scenario: You administer a vaccine and automatically circle V20.2 (Routine infant or child health check) on the superbill--but your payer denies the claim, asking you to itemize diagnoses to match the immunizations. Why?

Reality: The belief that V20.2 is the only code applicable to well-child vaccines is actually a myth. Although V20.2 is certainly the most common diagnosis code for this purpose, and is usually payable, it is not your only option.

On its Vaccine Coding Table, the American Academy of Pediatrics (AAP) notes that such requests are possible during well-child checks (http://practice.aap.org/content.aspx?aid=2334), stating, "ICD-9-CM guidelines indicate that immunizations administered as part of a routine well-baby or well-child check should be reported with code V20.2. The [specific immunization V] codes listed in this table can be reported in addition to V20.2 if specific payers request them. Immunizations administered in encounters other than those for a routine well-baby or well-child check should be reported only with the [V] codes listed in this table."

Therefore, if your payer specifically requests individual ICD-9 diagnoses linked to each vaccine administered during a well-child visit, refer to the AAP's table. For instance, a live MMR vaccine (90707) would be billed with V06.4 (Need for prophylactic vaccination with measles-mumps-rubella [MMR] vaccine).

Myth 2: You Can't Collect When Testing for Previous Vaccinations

Scenario: You see a foreign-born adopted child and you aren't sure if she had previous vaccinations, so you perform a Hep B Surface Ab and a Varicella-Zoster Ab, IgG. You write off the costs for these tests since they are for your own edification and you believe they are not billable.

Reality: You should be paid for this testing. In this situation, you should use V codes to tell the insurer why you performed the testing. The following codes may apply to your situation, depending on the documentation:

• V15.83 -- Personal history of underimmunization status
• V01.79 -- Contact with or exposure to other viral diseases
• V01.71 -- Contact with or exposure to varicella
• V05.3 -- Need for other prophylactic vaccination and inoculation against a single disease; viral hepatitis
• V05.4 -- Need for other prophylactic vaccination and inoculation against a single disease; varicella

The facts: The ICD-9 manual lists V codes under the category heading "Supplementary Classification of Factors Influencing Health Status and Contact with Health Services." This means that V codes often describe chronic conditions or underlying circumstances that might affect a patient's current health status or treatment.

How does this help you? Sometimes the V code will provide just enough information to turn a denial into appropriate reimbursement. Keep in mind that V codes can be the primary diagnosis codes for a visit.

Myth 3: Keep Billing 90474 for FluMist With Other Vaccines

Scenario: The pediatrician administers a FluMist immunization for a child under the age of 18 when other vaccines are billed on the same day, and counsels the parent on all of the vaccines he administered. You report +90474 for the FluMist but the insurer denies the claim.

Reality: If the physician or other qualified health care professional is providing counseling for a child less than 19 years of age, then the "new" pediatric component-based codes (introduced in 2011) should be used, regardless of who actually administers the vaccine.

In the case of FluMist, a one component vaccine, 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) would be the correct code to use. If it was a nurse-only "flu clinic" encounter, 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]) would be the correct code, if it is the initial or only vaccine administered at the visit.

Code +90474 (...each additional vaccine [single or combination vaccine/toxoid]) would only be accurate if there was another vaccine given as a nurse-only visit at the same encounter, and the FluMist is a subsequent administered vaccine.

Myth 4: Ensure Counseling Is Documented for 90460-90461

Scenario: Your nurse administers vaccines but the physician does not come in and counsel the patient about the immunizations. You report vaccine codes 90460 and 90461 for this patient.

Reality: You absolutely should not report these codes if no counseling was provided at the encounter when the vaccine is administered. Both 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component) and +90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component [List separately in addition to code for primary procedure]) state, "with counseling by physician or other qualified health care professional."

The ultimate determination on which practitioners can perform counseling is determined on an individual state-by-state basis according to the state-defined scope of practice.

CPT® 2012 places new restrictions on who is considered an "other qualified healthcare professional." Based on this, the American Academy of Pediatrics feels an "other qualified healthcare professional" applies to NPs and Pas as differentiated from other clinical staff (RN, LPN, and MP).

Bottom line: Check your state and insurer guidelines and keep a copy of those requirements in writing so you can quickly select the appropriate vaccination code based on which practitioner performed the service.

Myth 5: You Can Append Modifier 52 When Child Balks at Vaccine

Scenario: You are just about to administer a vaccine to a five-year-old child when she begins screaming uncontrollably at the sight of the needle. Unable to calm her down, her mother asks if she can reschedule the visit. You report the vaccine code with modifier 52 (Reduced services appended).

Reality: You cannot bill for a vaccine that you did not administer, and appending a modifier to the code doesn't change that. You didn't perform a reduced vaccine service--you performed no vaccine service. If the nurse performed vaccine counseling and a medically necessary E/M visit, you may be able to report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal ...).

If the patient refuses the vaccine, you'll link a code from the V64.x series (Persons encountering health services for specific procedures not carried out) to any code you bill for the service.

Drug cost consideration: In addition, if the vaccine is thawed or drawn up by the practitioner before the patient refuses it, you may have to dispose of the drug if no other patient is scheduled for the same vaccine before the expiration timeframe for your injection. For instance, if you had drawn up a drug that is only useable for 30 minutes and you don't have another patient scheduled for that same vaccine within the next 30 minutes, you know the drug will be wasted. In that situation, you should tell the parent that he will have to pay for the cost of the wasted drug if the child still refuses it.