Primary Care Coding Alert

Question: How should I bill the administration of the second and third shot of Gardasil? Should I also use code 99211?

Ohio Subscriber

Answer: Gardasil helps to prevent cervical cancer, precancerous genital lesions and genital warts due to human papilloma virus (HPV) types 6, 11, 16 and 18. Because the product is approved for use in females 9-26 years of age, you should report administration code 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) if that is the only injection service that day.
 
For the product Gardasil (quadrivalent HPV [Types 6, 11, 16, 18] recombinant vaccine), you should report 90649 (Human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use).

ICD-9 contains no specific diagnosis for vaccination against HPV. Because HPV is a viral disease, use V04.89 (Need for prophylactic vaccination and inoculation against other viral diseases; other viral diseases).

If the patient is only returning for her second or third Gardasil injection, you should not normally bill 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician). If the nurse records clinical data including evaluation and management components that justify the use of the code, you may be able to justify billing 99211.

Reviewing a pregnancy-assessment questionnaire could support the code's use. Make sure to document any pertinent items and attach modifier 25 to 99211 to indicate that the E/M service was significant and separately identifiable from the vaccine administration.

Warning: Be careful about offering Gardasil vaccination until coverage issues are sorted out. Because the CDC issued a provisional ACIP recommendation on the vaccine, most payers are covering the vaccine.