VEXING VACCINES

THE INS AND OUTS OF CODING VACCINES

Challenges: Patient Age Live virus or split virus Preservative free or with preservative Combo vaccine or individual vaccine Route of administration Appropriate administration codes

With or without counseling Route of administration (intramuscular, oral, intranasal) Number of vaccines or components given

State vs. provider supplied vaccines Insurance billing requirements.

Administration codes and modifiers.

AGE-SPECIFIC VACCINES

Some vaccines are coded based on specified age ranges while others are not

Example:

90634 Hep A, pediatric/adolescent dosage, 3 dose schedule

90655 Influenza, ……… children 6 – 35 months of age

90714 Tetanus and diphtheria toxoids …..7 years or older

90707 Measles, mumps and rubella, live, for subcutaneous use

VACCINE QUALITIESIt is important to know the qualities of the vaccine being provided as this can change the CPT code “with preservative” or “preservative free” Live virus or split virus Trivalent or Quadrivalent (Influenza vaccines) 7 Valent or 13 Valent (Pneumococcal)

Example:90655 – Influenza virus vaccine, trivalent, split virus,

preservative free, when administered to children 6 – 35 months of age, for intramuscular use.90687 – Influenza virus vaccine, quadrivalent, split virus,

preservative free, when administered to children 6 - 35 months of age, for intramuscular use.

CPT CODESThe vaccine codes range from CPT 90476 – 90749

New Codes for 2015:90651 – Human Pappillomavirus vaccine

types 6, 11, 16, 18, 31, 33, 45, 52, 58, non-valent (HPV), 3 dose schedule, for intramuscular use

90630 – Influenza virus vaccine, quadrivalent, (IIV4), split virus, preservative free, for intradermal use

ADMINISTRATION CODESVaccine administration codes are broken down into three categories:

1. Vaccines without Counseling (90471-90474)

2. Vaccines with Counseling (90460 – 90461)3. Vaccines for Medicare (G0008, G0009,

G0010)

WITHOUT COUNSELINGMost vaccines are given as intramuscular or subcutaneous injections and are reported using administration codes

90471 Initial vaccine+90472 Subsequent vaccines

However, there are a few oral and intranasal vaccines that are reported using administration codes

90473 Initial vaccine+90474 Subsequent vaccines

INITIAL VACCINEIf one or more vaccines are performed during an encounter specify an initial administration code first. · 90471 – Immunization administration for

percutaneous, intradermal, subcutaneous or intramuscular injections, initial

· 90473 – Immunization administration for intranasal or oral route, initial

Only one initial administration code should be listed per encounter. When both injectable and oral/intranasal vaccines are performed during the same visit, report 90471 as the initial administration code.

SUBSEQUENT VACCINESIf more than one vaccine is administered on the same day, a second or third administration fee is required to document the additional vaccines. All subsequent vaccine codes are classified as add-on codes and must never be reported without an initial administration code (90471 or 90473).

The definitions for the subsequent administration codes are as follows:

· + 90472 – Immunization administration for percutaneous, intradermal, subcutaneous or intramuscular injections, each additional vaccine

· + 90474 – Immunization administration for intranasal or oral route, each additional vaccine

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

5 Injectable Vaccines:

90471 x1 unit (Initial) 90472 x4 units (Subsequent) 1 Intranasal, 2 Oral Vaccines: 90473 x1 unit (Initial)90474 x2 units (Subsequent)

4 Injectable & 1 Oral Vaccine: 90471 x1 unit (Initial)90472 x3 units (Subsequent)90474 x 1 unit (Subsequent)

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COUNSELING & ADMINISTRATION

Pediatric immunization administration codes:

90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component

+90461: Each additional vaccine/toxoid component (list separately in addition to code for primary procedure)

Report multiple units of code 90460 for each first vaccine/toxoid component administered. No modifier should be required when reporting multiple first components. Note also that code 90460 does not apply only to combination vaccines, but also to single component vaccines (such as influenza, human papilloma virus, or pneumococcal conjugate vaccines).

The base code is reported for each vaccine administration to patients 18 years of age and under who receive counseling about the vaccine from a physician or qualified health care professional at the time of administration. Code 90461 is an add-on code reported for each additional vaccine component administered.

For example: MMR (Measles, Mumps and Rubella).How would you code the administration of this vaccine?Answer: 90460, 90461 x 2

CREATE TOOLS OR REFERENCE OTHERS

Diphtheria and Tetanus Toxoids

AdsorbedDT (pediatric) 2 90460, 90461 90702 V06.5

Tripedia® DTaP 3 90460, 90461, 90461 90700 

V06.1

INFANRIX®DTaP 3 90460, 90461, 90461 90700

 V06.1

DAPTACEL® DTaP, 5 Pertussis antigens 3 90460, 90461, 90461 90700 

V06.1

PEDIARIX® DTaP-Hep B-IPV 5 90460, 90461, 90461, 90461, 90461 90723 V06.8TriHIBit® DTaP-Hib 4 90460, 90461, 90461, 90461 90721 V06.8Pentacel® DTaP-Hib-IPV 5 90460, 90461, 90461, 90461, 90461 90698 V06.8KINRIX™ DTaP-IPV 4 90460, 90461, 90461, 90461 90696 V06.3

HAVRIX® DTP 3 90460, 90461, 90461 90632 

V06.1VAQTA® Hep A, adult 1 90460 90632 V05.3HAVRIX® Hep A, adult 1 90460 90633 V05.3VAQTA® Hep A, ped/adol, 2 dose 1 90460 90633 V05.3HAVRIX® Hep A, ped/adol, 2 dose 1 90460 90634 V05.3Twinrix® Hep A, ped/adol, 3 dose 1 90460 90636 V05.3

RECOMBIVAX HB® Hep A-Hep B 2 90460, 90461 90744 V05.3

ENERGIX-B®Hep B, adolescent or

pediatric1 90460 90744

 V05.3

RECOMBIVAX HB®Hep B, adolescent or

pediatric1 90460 90743

 V05.3

RECOMBIVAX HB® Hep B, adult 1 90460 90746 V05.3

ENERGIX-B® Hep B, adult 1 90460 90746 V05.3

EXAMPLE

An 11-year old girl presents for a preventive visit (99393). In addition, the child and her mother are counseled by the physician on risks and benefits of HPV (90649), Tdap (90715) and seasonal influenza (90660) vaccines. The mother signs consent to administration of these vaccines. A nurse prepares and administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is no immediate adverse reaction.

CPT Codes reported are:99393.25 - Preventive service90649 - HPV vaccine90460 - Administration first component (1 unit)90715 - Tdap vaccine90460 - Administration first component (1 unit)90461 - 2 additional components (2 units)90660 - Influenza vaccine, live, for intranasal use90460 - Administration first component (1 unit)

DOCUMENTATION REQUIREMENTSStandards set by the National Childhood Vaccine Injury Act (NCVIA) -Enacted in 1986Vaccines covered include diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), varicella, seasonal influenza (inactivated and live attenuated), pneumococcal conjugate, meningococcal, rotavirus, and human papillomavirus (HPV) vaccine.

1) Vaccine Manufacturer2) Lot number of the vaccine3) Date of administration4) Name, office address and title of healthcare provider

administering the vaccine5) Vaccine Information Sheet (VIS) edition date provided for

each vaccine6) Date VIS is provided to the patient, parent, or guardian.

MEDICARE REQUIREMENTSMedicare currently only covers 2 vaccines under Part B for preventative: Influenza (the flu);

The seasonal flu shot currently includes both a seasonal flu shot and an H1N1 (swine flu) vaccination.

Pneumonia; There are two separate, different doses of the pneumonia vaccine that are

provided at least a year apart;

Hep B – High Risk criteria must be met

Vaccines covered based on diagnosis: Diptheria/Tetanus (DT) – Injury only

All other commercially available vaccines are covered under Medicare Part D if the patient has this benefit.

Administration coding:G0008 – Administration of influenza virus vaccineG0009 – Administration of pneumococcal vaccineG0010 – Administration of Hepatitis B vaccine

VACCINES ADMINISTERED DURING WELL-CHILD VISITSWhen vaccines are provided as part of a well-child encounter, the ICD-9 guidelines instruct that code V20.2 (routine infant or child health check) includes immunizations appropriate to the patient's age. A code from categories V03-V06 may be used as a secondary code if the vaccine is given as part of a preventive health care service, such as a well-child visit.

What does the payer want??

VACCINES FOR CHILDRENThe Vaccines for Children (VFC) program is a federally funded program that: Provides vaccines at no cost to children

(age 0 to 18) who might not otherwise be vaccinated due to the inability to pay.

Allows providers to charge a vaccine administration fee based on the Centers for Medicare and Medicaid regional vaccine administration fee cap rates.

VFC ELIGIBILITYAs Providers of VFC vaccines we have a responsibility to screen for VFC eligibility and document eligibility status.

Screening to determine VFC eligibility and documenting the current VFC eligibility status must take place at each immunization visit for all patients birth through 18 years of age. Screening results must be documented at each immunization visit even if there is no change in eligibility status.

The only factors that can be considered when screening for VFC-eligibility are age and whether the child meets the definition of at least one of the following categories: Medicaid eligible, uninsured, American Indian/Alaska Native, and underinsured.

VFC ELIGIBILITYVFC eligibility categoriesChildren birth through 18 years of age who meet at least one of the following criteria are eligible to receive VFC vaccine: Medicaid-eligible: A child who is eligible for the

Medicaid Program. For the purposes of the VFC program, the terms "Medicaid-eligible" and "Medicaid-enrolled" are equivalent and refer to children who have health insurance covered by a state Medicaid program

Uninsured: A child who has no health insurance coverage

American Indian or Alaska Native: A child who meets the definition as defined by the Indian Health Care Improvement Act (25 U.S.C. 1603)

Underinsured: A child who has health insurance, but the coverage does not include vaccines; a child whose insurance covers only selected vaccines (VFC-eligible for non-covered vaccines only).

BILLING FOR VFC SUPPLIED VACCINESVFC Vaccine must be provided at no cost.

Patients, Medicaid agencies, and third party payers cannot be billed for the cost of VFC vaccine.

ADMINISTRATION FEES FOR VFC VACCINESVFC providers can charge a vaccine administration fee. The administration fee is per vaccine and not per antigen within the vaccine (combination vaccines).

For non-Medicaid, VFC-eligible children (American Indian/Alaska Native, uninsured, underinsured), VFC providers cannot charge the eligible child’s parent/legal guardian a vaccine administration fee that exceeds the maximum regional charge determined by the Centers for Medicaid and Medicare Services.

For Medicaid VFC-eligible children, VFC providers must accept the reimbursement for immunization administration set by the state Medicaid agency or the contracted Medicaid health plans.

Contact your local immunization program to check the maximum vaccine administration fee.

RESPONSIBILITY TO PROVIDEVFC providers cannot deny administration of a federally purchased vaccine to an established VFC-eligible patient because the child's parent/guardian/individual of record is unable to pay the vaccine administration fee.

The only fee that must be waived is the vaccine administration fee. Other visit or office fees may be charged as applicable.

SUBMITTING CLAIMS TO INSURANCE FOR VFC VACCINES

Guidance can be found on the Washington Vaccine Associations website:http://www.wavaccine.org

SUPPLYING VFC VACCINESThere are many regulations related to being a supplier of VFC vaccines. If your office is providing these services I would recommend that you use the following link to educate yourself and/or your team on these requirements:

http://www2a.cdc.gov/nip/isd/ycts/mod1/courses/vfc/10000.asp?student_id=

REFERENCES www.immunize.org www.cdc.gov/vaccines/hcp/vis/index.ht

ml www.wavaccine.org https://

fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf