Pediatric Coding Alert

Find out what you should report when the patient decides against immunization.

Coding for human papilloma virus (HPV) vaccine administration can get tricky when the patient refuses the vaccine after extensive counseling or when the patient is a male. Read on for three HPV vaccine myths and how good documentation can help your coding cause.

Myth 1: You Won't Get Paid for Extra Counseling

Being paid for extensive counseling in conjunction with the HPV vaccine might be difficult, but isn't impossible.

Background: CPT limits physician counseling as part of vaccine administration to children through 8 years of age (90465-90468). When the child passes age 8, you shift to vaccine administration codes 90471-90474 and this code set doesn't contain a counseling component. HPV vaccine administration can begin with children at age 9, which means you turn to codes such as 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injection{s}]; 1 vaccine [single or combination vaccine/toxoid]). You'll also submit 90649 (Human Papilloma virus [HPV] vaccine, types6, 11, 16, 18 [quadrivalent], 3 dose schedule, for intramuscular use) for the vaccine itself.

Challenge: Physicians potentially can spend a significant amount of time explaining the vaccine's purpose and answering questions from the parents or patient. That time isn't factored into 90471 or related codes, so providers want appropriate reimbursement when justified.

Option: HPV includes counseling on reducing sexual behavior risks. When the physician spends 15 minutes counseling the patient, you could report 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes). Include a diagnosis such as V65.45 (Counseling on other sexually transmitted diseases).

"The 99401 is truly time driven, so if you were at 10 minutes you wouldn't use it," says Richard Lander, MD, FAAP, a pediatrician and clinical assistant professor of pediatrics at University of Medicine and Dentistry of New Jersey. However, Lander says you could report a low-level E/M code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ) for a visit lasting approximately 10 minutes or 99213 for a visit lasting close to 15 minutes. Choose 99214 if a visit lasts 25 minutes.

Modifier potential: If you submit an E/M code and your staff administered the vaccines during a well visit, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Myth 2: You Can't Report Anything for Refusal

The physician spends 10 or 15 minutes talking with a patient and her parents about the HPV vaccine. They decide against having the immunization, but that doesn't mean you can't code and bill for the provider's time and effort.

Solution: If the counseling is separate from other E/M services, you can report the most appropriate E/M code, such as 99212. "If I spend more than the usual amount of time to counsel, I would code 99212 if the time spent was more than 60 seconds but less than 10 minutes," Lander says.

Include V64.06 (Vaccination not carried out because of patient refusal) on the claim with supporting documentation.

Myth 3: HPV Pay Only Applies to Females

Insurance carriers sometimes deny claims for administering the HPV vaccine to male patients. You can still be paid, however, whether by the insurance company or the patient's family.

"We've found that a growing number of insurers now cover Gardasil for males for the same ages as female patients (ages 9 to 26)," says Jeff Winokur, CEO of Atlantic Health Partners, in Farmington, Conn. "As with any new service or vaccine, you should contact your contracted insurance plans for their policies."

Plan ahead: Discuss the situation with the patient and his parents prior to vaccine administration and explain that their insurance might not pay. Ask the parents to sign an Advance Beneficiary Notification (ABN) accepting responsibility in case of insurance refusal.