Posted and filed under Coding, Compliance, Medical Record Auditing.

Vaccine administration coding and documentation is often confused by many providers, billers, coders, and even auditors.  One misunderstanding is what exactly is a toxoid component? And what documentation is necessary to support billing vaccine administration with counseling?  Here’s a quick look at the codes we are talking about.

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A toxoid component according to CPT refers to all antigens is a vaccine that prevents disease(s) caused by one organism.  Multivalent antigens or multiple serotypes of antigens against a single organism are considered a single component of vaccines.  For the case of clarifying what a toxoid component is, please review the chart below originally published by the American Academy of Pediatrics.

(Frequently Asked Questions for the Pediatric Immunization Administration Codes)

This chart shows how many components are included with common pediatric vaccinations and which Immunization Administration (IA) codes would be reported with each.

Counseling is a critical element in choosing the correct code for IA service being performed.  CPT indicates that 90460 and 90461 are to be used to report vaccine immunization administration with counseling and the code set of 90471-90474 should be used when counseling is not completed.  What constitutes counseling? – A face-to-face discussion is performed by; the physician/ or other qualified health care professional; with the patient or care giver. Typical items reviewed as part of the counseling are risks and benefits of vaccination, patient/ care giver concerns, signs and symptoms of adverse effects, and when to seek medical attention for any adverse effects.

Remember the old adage “If not documented, not done”? It is best practice to include in the documentation a summary of the items discussed during the counseling portion of the visit. Beware of using a template or cut and paste statement, even worse a CPT code listed at the end of the note is not sufficient to support performance of the service.

The AAPC published an article in which it defined “A note might include all vaccine components recommended at this visit, a notation that each component had counseling, and any issues discussed specific to those patient risk factors.” (Lisa Jensen, 2011)

Example:

A 16 year old patient is counseled on the risks and benefits of Rabies, Diphtheria-tetanus-pertussis-hepatitis B-poliovirus vaccine (DTap-Hep B-IPV), and has no counseling for the Influenza virus vaccine.  It is noted that the provider administers each vaccine, documents complete chart notes and registry information, and verifies that there is no immediate adverse reaction to the vaccines.

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Works Cited

Frequently Asked Questions for the Pediatric Immunization Administration Codes. (n.d.). Retrieved June 2, 2015, from American Academy of Pediatrics: http://www2.aap.org/immunization/pediatricians/pdf/faqiacodes.pdf

Lisa Jensen, M. F. (2011, July 1). Stick to the Facts on Childhood Immunization Coding. Retrieved June 2, 2015, from AAPC, The Coding Edge: http://news.aapc.com/stick-to-the-facts-on-childhood-immunization-coding/

American Medical Association.  Professional Edition Current Procedural Terminology (CPT). Chicago: AMA, 2014.