Primary Care Coding Alert

Despite vaccine program variations, one constant exists: You should always code for the vaccine, even if your office gets the product for free. 
 
Many FP coders think that no charge means no code. So, if their FP enrolls in a state-funded vaccine program, such as Vaccines for Children (VFC), they follow the state guidelines for reporting an immunization administration code, such as 90471-90474, but they omit the vaccine code (90476-90749).

Two Reasons to Always Code the Product

Correct coding and state vaccination guidelines require you to report the specific vaccine administered regardless of coverage. CPT instructs coders to report all performed services. With the administration codes, CPT specifically states, "Codes 90471-90474 must be reported in addition to the vaccine and toxoid code(s) 90476-90749."
 
In addition, many VFC programs indicate that you should report the specific vaccine. For instance, Indiana Medicaid's VFC program instructs free vaccine providers to "use the specific CPT procedure code for the specific vaccine administered." Although the program does not reimburse the physician for the vaccine cost, you still have to code the product used. "Reporting the specific product allows the state to know what specific vaccines the physician administered," says Dalrona Harrison, RN, BS, CCS-P, CPC, American Academy of Professional Coders professional medical coding curriculum instructor and coding manager for Via Christi Medical Management in Wichita, Kan.

Don't Charge for the Free Vaccine

To code the vaccine product without charging for it, you should report the appropriate vaccine code (90476-90749) and enter a $0 or no charge (N/C) in the charge column of the CMS-1500 form, Harrison says. For instance, a mother brings her 15-month-old infant to your FP for a well check. After the E/M service, a nurse administers a combination measles, mumps, rubella virus vaccine (MMR) and a combined diphtheria, tetanus toxoids, acellular pertussis vaccine and Hemophilus influenza B vaccine (DTaP-Hib). The child is on Medicaid, and your office uses state-supplied vaccines.
 
For the FP's exam, you should report the age-appropriate preventive medicine code. Use 99382 (Initial comprehensive preventive medicine evaluation and management of an individual ...; early childhood [age 1 through 4 years]) for a new patient and 99392 (Periodic comprehensive preventive medicine re-evaluation and management of an individual ...; early childhood [age 1 through 4 years]) for an established patient.
 
Also, you should report each vaccine administered. Use 90707 (Measles, mumps and rubella virus vaccine [MMR], live, for subcutaneous or jet injection use) for the MMR vaccine and 90721 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine [DTaP-Hib], for intramuscular use) for the DTaP-Hib vaccine. "You should not charge for the vaccine, since the state supplied it free of charge," says Sharon Belveal, clinic coordinator at Callaway Community Hospital and Clinics in Fulton, Mo. Enter either a $0 or an N/C in the charge column to show Medicaid that you used the state-supplied vaccines but are not requesting payment for them.
 
Depending on the state's VFC requirements, you should also report the vaccine administration. Use 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]) for the first vaccine administration and +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) for the second administration.

State May Include Administration in Vaccine

Some states, however, bundle the administration cost into the vaccine code. For instance, to code for vaccine administration for Missouri's VFC program, you have to use the product codes, not the administration codes, Belveal says. To charge for the administration, instead of reporting 90471-90472, you report the specific product (90707, 90721) and record the administration charge, such as $5, in the charge column of the CMS-1500 form. That way, the state can distinguish which vaccines the nurse gave, Belveal says. "An administration code would not allow the state to track the vaccines," she says.
 
"The state is paying for the professional service of administration and the cost of 'doing business,' such as supplies, staff and program paperwork," Harrison says. The Centers for Disease Control, the agency that oversees VFC, pays for and provides the vaccines.