Health Information Management

Take the sting out of coding slip-ups when reporting vaccinations at pediatric practices

JustCoding News: Outpatient, January 27, 2010

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Vaccinations and immunizations are some of the most frequently administered services at pediatric practices. Unfortunately, it is also common for coders to report them incorrectly, often resulting in missed reimbursement.

Children often receive multiple vaccinations in a single office visit. Coders will often report the different CPT and ICD-9-CM codes, but they forget to link the proper diagnosis code to the respective CPT code.

“For each vaccination that you give, there’s a diagnosis code that correlates to that particular vaccination,” says Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, vice president of business and member development for the American Academy of Professional Coders in Salt Lake City. “When there is a missing or improper diagnosis code, that claim rejects.”

Another common mistake coders make is while they code for multiple immunizations or vaccinations, they neglect to bill separate administration charges for each vaccine or immunization.

“For example, practices will often only bill two administrations even though they’ve given four vaccines,” Buckholtz says.

Coders also often mistakenly report code 90471 or 90472, which is for any age, instead of age-specific codes for services administered to younger children, says Jacqueline J. Stack, AAB, CPC, CPC-I, CEMC, CFPC, CIMC, CPEDC, CCP-P, billing, coding, and collection specialist at Seneca Medical Center, LLC, in Seneca, PA.

For example, use code 90467 to report immunization administration for patients younger than eight years old.

Note the following examples that illustrate proper coding.

Example 1
A 5-year-old receives the following vaccines: 

  • Diphtheria, tetanus, and pertussis
  • Polio vaccine
  • Measles, mumps, and rubella
  • Varicella
  • Hepatitis A

The physician counsels the parent, and the nurse gives the immunization. For this scenario, you should report the following immunization, diagnosis, and administration codes: 

  • 90700; V06.1; 90465
  • 90713; V04.0; 90466
  • 90707; V06.4; 90466
  • 90716; V05.4; 90466
  • 90633; V05.3; 90466

Example 2
A 2-month-old patient receives the following vaccines:

  • Rotavirus (oral)
  • Pentacel®
  • Hepatitis B
  • Prevnar®

The physician counsels the parent, and the nurse gives the immunization. For this scenario, you should report the following immunization, diagnosis, and administration codes:

  • 90680; V04.89; 90467
  • 90698; V06.3/V03.81; 90465
  • 90744; V05.3; 90466
  • 90669; V03.82; 90466

Note that because the rotavirus is oral, you should report a different administration code versus what you might report for an injection.

Understand rules for reporting modifier -25

Knowing when to apply modifier -25 can also trip up coders, particularly when it comes to coding well-visits, during which the physician treats another problem.

“They can bill for both services, but practices often forget to bill for either the well-visit or the additional E/M visit,” Buckholtz says. “Sometimes they don’t understand the rules for when they can bill for both services, and other times, they don’t understand the insurance billing process and worry that they patient will be billed.”

The following scenario illustrates a case in which it is appropriate to report modifier -25:
A patient presents for his well-child visit, and during the well-child exam the mother states the child has been complaining of foot pain. The physician examines the foot and orders x-rays.

For this case, it would be appropriate for the physician to bill both the well-child exam and an E/M visit with the modifier -25, Buckholtz says.

However, the following scenario illustrates a case for which it would not be appropriate to report modifier -25:
A patient presents for her well-child check, and during the exam the physician notes that the child’s ear is impacted with cerumen, and he cleans the ear to be able to better visualize the ear canal.

In this case, the problem is incidental to the exam and the practice should bill only the well-child visit, Buckholtz says.

Understanding the criteria for applying modifier -25 has can be confusing, especially because many times it depends on physician documentation clarifying the significance of the problem.

The physician would need to document sufficient additional work aside from the history of present illness, review of systems, or medical decision-making that they conduct for the well-visit, Stack says.

When a parent says his or her child’s ear hurts, the physician is going to take a look at the child’s ear anyway during the well-visit. The physician may ask additional questions about how long the child has been complaining of pain, but if the physician decides to just monitor the problem and not actively treat it, then the coder should not report a separate E/M service with modifier -25, Stack says.

However, if a child is coughing, wheezing, and is otherwise noticeably sick, the physician may order an x-ray, which confirms pneumonia. This clearly requires a higher level of medical decision-making, and it would be appropriate to report code 99212 with modifier -25, Stack explains.

Be aware of rules for reporting early screenings

Each state has early screening programs, which require certain tests at different intervals. If providers neglect to accurately report any of the requirements, then the provider will miss the higher reimbursement for that early screening, Stack says.

So become familiar with your state’s requirements for screening and reporting for (but not limited to) the following:

  • Hearing
  • Vision
  • Standard developmental
  • Autism

Know where to focus internal audits

One way to pinpoint potential coding problems is to follow a patient throughout the entire process, from the time he or she phones in to the time you drop the bill, Buckholtz says.

“Nurses could forget to circle the appropriate service on the superbill, or the check-in person might make a mistake in their data entry,” she says. “I always tell everyone to start looking at coding for vaccines; this is typically a big revenue flow for practices.”

Because pediatric practices typically provide a high volume of E/M visits, it’s also a good idea to audit E/M codes to ensure coders understand the different levels of services and are assigning the appropriate level codes, Stacks says.

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