Primary Care Coding Alert

To get reimbursed for giving a patient a vaccination, either on its own or as part of a preventive medicine services visit, you need to get paid for the vaccine itself, the administration and the visit unless the patient isnt seen by a physician. If a nurse sees the patient, you will get paid only for the vaccine and the administration.

Beyond this basic rule, however, there are numerous problems created partly by managed care, which isnt sure it wants to pay for the new administration codes (90471 for a single or combination vaccine, 90472 for each subsequent single or combination vaccine). These codes were actually instituted in 1999, but their definition was updated in 2000.

If you see a patient for a well visit and give a vaccination (or several), you would code the age-appropriate code (99381-99387 for new patients, 99391-99397 for established patients).

CPT 2000 Update

There is now a revised description which makes it possible for physicians to get paid more for administering each vaccine or combination vaccine especially when administering more than two. The vaccine administration codes issued in 1999 were found faulty immediately. Code 90471, which is for one vaccine, is fine. But 90472 is for two or more, and that, when physicians are frequently administering three, four, or even five is not fair. CPT 2000 redefined the second code to be for each subsequent vaccination. So now, practices will be able to bill for each vaccine they administer.

Medicare, however, does not recognize the 90471 or 90472 administration codes. Rather, for Medicare patients, you should use the HCPCS codes for administration. These are G0008 for flu, G0009 for pneumonia, and G0010 for hepatitis B, says Kent Moore, manager of reimbursement issues for the American Academy of Family Physicians (AAFP).

Now, lets say the patient is covered by a commercial HMO. A typical case for a family practice physician is a child coming in for immunizations which the physician decided not to give two weeks ago during the preventive medicine services visit because otitis media was discovered at the time. How should the vaccination-only visit be coded when the nurse is the only one who sees the child?

The answer, says Moore, is to use only the administration code and the vaccine product code. Do not use 99211, the nurse-visit code which most physicians were using prior to the new vaccine administration codes for 1999. Note that since the well visit is not actually being done in this example, you will not be able to use the well-visit diagnosis code; rather, you will need to use the specific vaccination code (V03.x, V04.x, V05.x, or V06.x). Some practices also use V05.8 (other specified diseases) or V06.8 (other combinations). (See below for discussion on diagnosis coding for vaccines.)

Also note that CPT 2000 has introduced the circle with a slash symbol, to indicate that a -51 modifier (multiple procedures) should not be used. This symbol appears on the vaccine codes. Therefore, in listing multiple vaccine codes you should not use the -51 modifier on the vaccines following the first vaccine. (This has always been true, but apparently CPT felt it was necessary to emphasize the point.) The -51 modifier is for multiple procedures and indicates you expect to be paid half the normal amount for this item.

What Diagnosis Codes?

There is confusion about what diagnosis codes to use when you administer vaccines. Should you use V20.2 (routine infant or child health check, including immunizations appropriate for age)? Or should you use the specific ICD-9 codes which go with each vaccine (such as V06.4 for MMR)? Or should you use V05.8 (need for other prophylactic vaccination and inoculation against single diseases; other specified disease) and V06.8 (need for prophylactic vaccination and inoculation against combinations of diseases; other combinations)?

While most physicians we have spoken to are using V20.2 and getting reimbursed for it, some are using the specific vaccine codes and getting reimbursed as well. So why does it matter which you use?

The American Academy of Pediatrics (AAP) says you should use the specific vaccine codes because using V20.2 implies that the child has to be well to get immunized. Instead, the AAP wants every child to be immunized, and therefore wants to encourage specific vaccine coding, so that a child with, say, otitis media can still be immunized.

You should still use V20.2 for the well visit (99381-99385, 99391-99395), but you should use the individual vaccine codesor the V05.8 and V06.8for the immunizations and the vaccine administration codes.

The Benefits of V20.2

The goal of getting every child immunized is laudable, but be prepared for a possibly harried biller if you use this method. Using each diagnosis code for each vaccine is extremely cumbersome because the HCFA 1500 claim form only allows four diagnoses. Physicians may well give four vaccines at once, and then if you also have to use a diagnosis code for a well- or sick-visitor bothyou will find you are juggling diagnoses between forms in order to get everything to fit. It is easy to see why coders prefer to use V20.2 down the line. And if you know they will be paid this way, you can indeed code V20.2, says Thomas Kent, CMM, president of Kent Medical Management in Dunkirk, Md. You have a choice, he says. On some computer systems, if you submit the claim electronically its a moot point anyway. Thats because each CPT code is treated individually, so theres no limit on the number of codes per date of service. If a specific insurance plan does not pay with the V20.0, then use the specific codes, recommends Kent.

However, when the vaccine is given alone or in conjunction with an office visit, then you must use the individual vaccine diagnoses codes.

Scenarios for HCFA 1500

Here are some examples of how you should code immunizations, under different scenarios in boxes 21 and 24 of the HCFA 1500 form.

Example 1: Preventive care services (6 months, established patient) (99391, periodic preventive medicine reevaluation and management of an individual including a comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures), with DTaP (90700), Hib (90645, 90648, or 90647, depending on what youre giving), oral polio vaccine (90712), and Hepatitis B (90744). Note that you must use the V06.8 (other combinations) for DTaP because there is no ICD-9 code for that combination, and V05.8 (other specified disease) for Hib because there is no ICD-9 code for Hib. Polio vaccines get a diagnosis code of V04.0. Note that you should also use 90471 for the first vaccine, and 90472 for each subsequent vaccine.

In Box 21, there are four slots for diagnosis codes. It doesnt matter in which order you put the diagnosis codes: Your reimbursement wont be affected in terms of this box. In this case, you are using five diagnoses. So to follow the AAPs suggestion, you would have to print two different HCFA 1500 forms, using the fifth diagnosis on the second form.

Example 2: Office visit (13 months, established patient) for oral thrush (likely 99212, diagnosis code 112.0). The child missed her one-year checkup and is behind on immunizations, so the pediatrician wants to vaccinate today, instead of risking the patient not returning for a well visit in the next few months and missing the shots altogether. Vaccinations to be given are Hib (90645, 90648, or 90647, V05.8), MMR (90707, V06.4), oral polio vaccine (90712, V04.0), and varicella (90716, V05.4). Again, you will use vaccine administration code 90472 since you are giving two or more vaccines. Note that in this example, you have no V20.2, because you are not providing an entire well visitthe parent didnt schedule one. Again, remember it doesnt matter in what order you list your diagnosis codes in Box 21. Its only where you put them in box 24, as indicated by the numbers, which could affect reimbursement.

Example 3: This is the same as example 2, except that the pediatrician, at the request of the parent, went ahead and did a complete physical, even though the parent hadnt scheduled one. In this case, you would code 99392, assuming the child is an established patient, and use the V20.2 diagnosis code for that CPT code. You would also append modifier -25 to the 99212 because you are using two E/M services codes on the same day.

Note that example 3 would also apply to this case if the patient came in for a scheduled well visit at 1 year, got the required immunizations, and also had teething problems.