Cash Injection: Accurate Coding for Vaccines Requires Precision, Attention to Detail

October 1, 2019

Patti A. Lewis
Director Business Office Services
PARA HealthCare Analytics, Inc., An HFRI Company

From flu to tetanus, vaccines are among the most common outpatient procedures providers administer on a day-to-day basis. But they can also be complex to code and bill, and undetected mistakes can result in continual underpayment for services rendered.

What makes vaccines so tricky? In most instances, coders must consider a range of factors to ensure the procedure is properly coded, and it can be easy to overlook specific details or nuances. This is especially true if multiple injections are given to a single patient during one encounter.

Some of the key variables associated with vaccine coding include:

  • Patient age
  • Insurance
  • Route of administration
  • Total number of vaccines given in the same encounter
  • Physician counseling
  • State vaccines programs

Q-Codes

Vaccine codes are published on a semi-annual basis, typically July 1 and January 1, by the American Medical Association (AMA). CPT® vaccine codes range from 90476 through 90749. In recent years, Medicare has created additional Q-codes for vaccines. Q-codes are reimbursed at reasonable cost to providers, and Medicare deductible and co-insurance amounts do not apply when the Q-codes are reported to Medicare.

Age-restricted vaccines

While many vaccines don’t have specific age requirements, others can be designated pediatric, adolescent or adult. As a result, it’s important for coders to confirm that the vaccine administered is appropriate for the patient’s age.

Code set administration

In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration. Administration codes encompass three general categories:

  • CPT® range 90471 — 90474 identifies vaccines without Counseling (over 18 years of age)
  • CPT® range 90460 — 90461 identifies vaccines with Counseling (thru age 18)
  • HCPCS Codes G0008, G0009 and G0010 are specific to Medicare beneficiaries

State programs

Some physician practices participate in state-sponsored Vaccines for Children (VFC) programs. Because the state generally provides the practice with the vaccines, physicians may not charge beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers.

However, providers may charge patients for the administration fee associated with providing the vaccine. For vaccines provided as part of the VFC program, the CPT® code range is 90476 — 90749, with modifier SL appended in the first reporting modifier field.

Route of administration

Ensuring the correct route of administration allows the coder to select the appropriate administration code. Most vaccines are given as injections and are reported using administration codes 90471 and 90472. But there are a few oral and intra-nasal vaccines that are reported using administration codes 90473 and 90474.

Initial vaccines

If one or more vaccines are administered during an encounter, it is necessary to specify an initial administration code first. Initial administration codes include:

  • 90471: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial
  • 90473: Immunization administration for intra-nasal or oral route, initial

Only one initial administration code is reported per encounter. If both injectable and oral/intra-nasal vaccines are performed during the same visit, providers should report 90471 as the initial administration code. Codes 90471 – 90472 have a slightly higher reimbursement than oral/intra-nasal administration.

Subsequent vaccines

If more than one vaccine is administered on the same day, a second or third administration code is required to document the additional vaccines. All subsequent vaccine codes (90472 and 90474) are classified as add-on codes and must be reported with an initial administration code. The definitions for subsequent administration codes are:

  • 90472: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, each additional vaccine
  • 90474: Immunization administration for intra-nasal or oral route, each additional vaccine

When three or more vaccines are performed during an encounter, units should be applied to the administration code for each additional vaccine of the same type (injectable or oral).

Here are some examples:

  • Five injectable vaccines: report 90471 X1 unit (initial) and 90472 X4 units (subsequent)
  • One intra-nasal and two oral vaccines: 90473 X1 unit (initial) and 90474 X2 units (subsequent)
  • Four injectable vaccines and one oral vaccine: 90471 X1 unit (initial) and 90472 X3 units (subsequent) and 90474 X1 unit (subsequent)

Keeping it all straight

Staying abreast of the latest coding directives can be a challenge, and it can be doubly so when it comes to vaccines, given all the factors that need to be accounted for to code and bill correctly. That’s why Healthcare Financial Resources Inc. (HFRI) and PARA HealthCare Analytics have partnered to deliver comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursement. Contact us today to learn more about the many ways we can help your organization.

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