Codapedia is now a division of Find-A-Code

Auditing Vaccines

July 28th, 2017 - Paul Chandler
Categories:   Audits/Auditing   CPT® Coding  
0 Votes - Sign in to vote or comment.

Auditing vaccines can be difficult, as precise attention needs to be paid to the documentation to extract all variables needed for proper coding. Details such as age of the patient, format of administration, counseling performed, and quantity are all needed to properly code. Being familiar with those variables is needed to audit the chart and coding.

Vaccinations administered with counseling are coded with CPT© codes 90460 and 90461. Both codes require the patient to be through 18 years of age. Injections, intranasal, and oral forms of administration are covered with these codes. The first component is used with code 90460, with each additional component addressed with code 90461. Part of the difficulty in coding, and later in auditing, is being knowledgeable with the number of components per vaccine. Some are easy, such as code 90636 (Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use) with two components. Others are more difficult to decipher. A good example is CPT code 90698: Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use. CPT code 90698 has five components. The proper administration when provided to a patient through 18 years of age, with counseling performed is: 90460, 90461 x 4.

Vaccinations administered without counseling to patients through 18 years of age have different coding options, based on the method of administration. Injections, whether it be percutaneous, intradermal, subcutaneous, or intramuscular are coded as 90471 for the first vaccine with 90472 used for each additional vaccine. Using the same example above, CPT 90698 would be coded with only one administration code, 90471, if the patient was through 18 years of age and no documentation of counseling being performed.

If the vaccine provided to the patient was given via intranasal or oral routes, with the patient being through 18 years of age with no documentation of counseling performed, the administration codes would be 90473 for the first vaccine, with 90474 for each additional vaccine.

Vaccine administration codes have a major impact on selection if the patient is through 18 years of age. The provider must document that he/she provided the patient counseling on the vaccines received. Depending on the coder and/or the office, the documentation may not support counseling was performed; however, the chart was coded with counseling because the physician may "always counsel her/his patients". The old phrase applies: if it is not documented, it did not happen.

For patients over 18 years of age the administration codes are more simplified. The physician does not get credit for counseling the patient in the code selection as codes 90460- 90461 would not apply. CPT codes 90471-90472 are used for the administration of vaccines performed by injection. CPT codes 90473-90474 are used for the administration of vaccines performed by intranasal or oral routes. Both code range sets apply per vaccine, not per component of the vaccine.

In auditing vaccines, the main focus is to be knowledgeable on the number of components per vaccine. With that information to audit, along with the understanding of the administration codes based on age, counseling, and route of administration, the auditor will be able to successfully ensure proper coding rules were followed for proper reimbursement.


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Q/A: How Many Diagnosis Codes do I use?
April 15th, 2019 - Wyn Staheli, Director of Research
Question: My patient has a lot of chronic conditions. Do I need to include all these on the claim? I know that I can have up to 12 diagnoses codes on a single claim. What if I need more than that? Answer: More is not always better. You only need to ...
Watch out for People-Related ‘Gotchas’
April 15th, 2019 - Wyn Staheli, Director of Research
In Chapter 3 — Compliance of the ChiroCode DeskBook, we warn about the dangers of disgruntled people (pages 172-173). Even if we think that we are a wonderful healthcare provider and office, there are those individuals who can and will create problems. As frustrating as it may be, there are ...
Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?
April 8th, 2019 - Wyn Staheli, Director of Research
Question: What do I do when a Medicare patient refuses to sign an ABN? Answer: That depends on whether the patient is still demanding to have/receive the service/supply. If they aren’t demanding the service, then there is no need to force the issue. Just make sure that you still have an ...
Prepayment Review Battle Plan
April 8th, 2019 - Wyn Staheli, Director of Research
Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...
Looking Ahead - Changes in Dentistry!
April 3rd, 2019 - Christine Taxin
In the next 10 years, what is the biggest change dentistry will experience? FW: We all know healthcare in the U.S. is changing rapidly. Dentistry is no exception. My opinion is that several big changes are forthcoming. Most often, I think about changes that benefit patients and/or providers. Here are three ...
Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?
April 1st, 2019 - Wyn Staheli, Director of Research
I submitted a claim to the VA and it’s being denied. Why? There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic ...
Corrections and Updates
April 1st, 2019 - Wyn Staheli, Director of Research
One constant in our industry is change. Policies change, contracts change, and there are updates. Also, people aren’t perfect and mistakes can be made. So this article will cover a variety of topics. Published Articles We appreciate feedback from our valued customers. We have received feedback regarding two of our articles which ...

About Codapedia & Find-A-Code Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™/Find-A-Code™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association