Pediatric Coding Alert

Check out the new V code that helps you explain catch-up immunizations to your payers.

If your practice sees a new 8-year-old patient who has never received a vaccine and her mother now wants to start the process, how should you bill Medicaid when the vaccines aren't age appropriate?

"This situation is not uncommon, but when it happens it's important to catch up as quickly as possible," says Richard L. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

The next time you're faced with a similar scenario, follow our experts' advice for an easy transition on all sides.

The Patient's Age Guides Vaccines -- And Your Coding

Whether you're coding for a child who's behind schedule or starting late, the child's age helps guide the vaccinations. Remember: "Falling behind schedule" means the child is more than one month late with a vaccine, according to the American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP). The 2010 catch-up schedule draws the line between children ages 4 months to 6 years and ages 7 through 18 years.

"The schedules are very clear and are laid out according to the products, the age at which the products are used, and the minimum intervals between doses to get the patient caught up," Tuck says.

Handy tools: You can find the catch-up schedules online from the AAP (www.aap.org). The CDC website offers an interactive tool to determine how you should update missed vaccines at http://www.cdc.gov/vaccines/recs/Scheduler/catchup.htm.

Check What You Can -- or Can't -- Give

Once the child passes a certain age, you can't administer certain vaccines. Because the child in the scenario above is 8, you cannot administer non-age appropriate vaccines such as DTaP (90700, Diphtheria, tetanus toxoids, and acellular pertussis vaccine [DTaP], when administered to individuals younger than 7 years, for intramuscular use) or Hib (90645, Hemophilus influenza b vaccine [Hib], HbOC conjugate [4 dose schedule], for intramuscular use). You can, however, administer IPV, MMR, Varivax, and Hepatitis B and A to children in her age group.

Tdap has less pertussis antigen than DTaP, so "it's more easily accepted by the immune systems of adolescents and/or adults," explains Kris Cuddy, CPC, CIMC, of KC Medical Consulting Services in DeWitt, Mich. "Hemophilus influenza B (Hib) is a disease primarily of little kids, so older kids don't need the vaccine," adds Nancy Bishof, MD, a pediatrician in Lexington, Ky.

"Prevnar is meant for children under ages 5 or 6. If a child needs a vaccination at age 8 you would use Pneumovax instead."

At first glance, the easiest way to update vaccines for the 8-year-old in our example is to administer Tdap (90715, Tetanus, diphtheria toxoids and acellular pertussis vaccine [Tdap], when administered to individuals 7 years or older, for intramuscular use). The immunization schedule, however, states that you should only use Tdap in the catch-up series or as a booster for children ages 10 to 18. Because the child in our example is 8, you have two other options instead.

Option 1: Administer Td (90714, Tetanus and diphtheria toxoids [Td] adsorbed, preservative free, when administered to individuals 7 years or older, for intramuscular use) at the first visit, linked to diagnosis V06.5 (Tetanus-diphtheria [Td] [DT]). Give a second dose of Td four weeks later; give the third does of Td six months after that point. When the child reaches age 10 or 11, administer Tdap (90715).

Option 2: Vaccinate completely with DT (90702, Diphtheria and tetanus toxoids [DT] adsorbed when administered to individuals younger than 7 years, for intramuscular use), administering all four doses at the scheduled times. Wait until the child's tenth birthday to administer the TdaP vaccine.

Caution: "I don't know if many pediatricians even stock Td vaccine since TdaP came out," Bishof says.

If the pediatrician wants to administer Td but doesn't keep it in stock, Tuck makes this suggestion: "You could give the patient a prescription for Td. The parents can get the prescription filled and bring the immunization product to your office for administration." You would report V06.5 (Need for prophylactic vaccination and inoculation against combinations of diseases; tetanus-diphtheria [Td] [DT]) along with the proper administration code.

Include V Codes to Explain Reasons

ICD-9 2010 introduced a new code that helps you explain catch-up immunizations to your payers: V15.83 (Personal history of underimmunization status). "Code V15.83 can explain to an insurance carrier why an immunization might be given late," Cuddy says. "The code can also advise non-compliance of patients who were previously up-to-date on their immunizations."

Include V15.83 as the secondary code after the code for the immunization.

Bonus: You can use V15.83 to track lapses in vaccinations. Having the information at your fingertips can help you communicate with your patients' parents and ideally get the child back on schedule sooner.