6 Tips to Help Practices Charge Correctly for Immunizations

By Lisa Eramo  |  May 9, 2017

Pediatricians, primary care physicians, and internists frequently perform immunizations, but are they charging correctly for these services?

Oftentimes, the answer is no, says Raemarie Jimenez, manager of new product development at AAPC, an organization representing professional coders, billers, auditors, compliance professionals, documentation specialists, and practice managers. That’s because a single immunization could require multiple codes. In addition, immunization codes are age-based and may include other requirements, such as counseling and patient education.

Jimenez provides six tips to help practices report immunizations correctly.

  1. Report ICD-10-CM code Z23 once for all vaccinations given during the encounter. When the purpose of the visit is to vaccinate the patient—and the physician doesn’t address any other concerns—then code Z23 is the only diagnosis code that should appear on the claim, says Jimenez. However, patients often receive vaccinations during preventive exams, in which case multiple diagnosis codes (including Z23) should be present, she adds.
  2. Don’t forget the supply code. Consider one or more codes from CPT range 90476-90749 to denote the specific supply/drug that was administered. One caveat is that physicians shouldn’t report a supply code if they receive the drug for free, says Jimenez. For example, some state Medicaid programs supply vaccination supplies to providers at no charge.
  3. Determine whether the provider performed counseling at the time of vaccine administration. Report codes 90460 and 90461 only when a physician or qualified healthcare professional provides face-to-face counseling, such as education regarding side effects, the benefits of the vaccine, or what to do if the patient experiences a reaction to the vaccine. If no counseling was performed, report codes 90471-90474—regardless of the patient’s age. Don’t assume that counseling occurs with every vaccination, says Jimenez. Sometimes the physician doesn’t counsel the patient or counseling isn’t warranted (e.g., in the case of a series of vaccinations). “If the patient gets a series of vaccinations, they might not need counseling each and every time. They’d get counseling the day it’s administered,” she adds.
  4. Consider the patient’s age when reporting a code for the vaccine administration. If the patient is 19 years of age or older, report one or more codes from CPT range 90471-90474, depending on the method of administration. Note that codes 90471 and 90473 denote the initial vaccine while codes 90472 and 90474 denote each additional vaccination. If the patient is 18 years of age or younger and the provider performs counseling, report CPT code 90460 for the first component of the vaccination and code 90461 for each additional component of the vaccination.
  5. Know when to code ‘per component’ of the vaccine. Codes 90460 and 90461 require a separate code for each component when a single vaccine includes multiple components. For example, when administering the MMR vaccine, report 90460 for the initial component (measles) and 90461 twice—once for the mumps and once for rubella. The same is true for other combination vaccines, such as DTaP (diphtheria, tetanus, and acellular pertussis).
  6. Report HCPCS administration codes for Medicare patients in certain circumstances. This includes when patients receive these vaccinations:
  • Pneumococcus (G0009)
  • Influenza (G0008)
  • Hepatitis B (G0010)

These codes replace CPT codes 90471-90474, says Jimenez.

Importance of immunization data quality

Why is it important to ensure compliance when billing immunizations?

First, there are revenue implications. Medicare, for example, reimburses approximately $26 per immunization, and commercial payers as well as Medicaid may pay even more. This doesn’t include the cost of the drug itself—something for which physicians may be able to bill as well. For practices that perform a large number of immunizations, this could translate to ample reimbursement.

Second, immunizations may help physicians achieve a higher score under the Merit-based Incentive Payment System (MIPS), particularly if they plan to report one or more of the following quality measures:

  • Preventive care and screening – influenza administration
  • Childhood immunization status
  • Immunizations for adolescents
  • Influenza immunization

“Immunizations are something physicians ask patients about each year,” says Jimenez. “They maintain vaccination records especially for children. It’s easy from a documentation perspective to comply with these measures.”

Third, payers are becoming more interested in quality. Jimenez says it’s possible that payers could eventually want to track whether counseling performed at the time of administration helps reduce complications, increase patient compliance with series-based vaccinations, and even keep individuals out of the emergency department. 

“These are the types of things that we’re hoping some of these quality programs produce—finding efficiencies in medicine and the best practices that keep patients the healthiest while also reducing cost,” says Jimenez. “People need to stop thinking ‘code equals reimbursement’ and start thinking about all of the other information we get from code.”

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