The answers to three frequently asked questions may surprise you.
Here are three frequently asked questions (FAQs) about vaccination coding and billing. Confirm your skills for reporting these common primary care procedures by reviewing the answers.
Question 1: If a patient comes in for a vaccination only, are they considered an established patient to the practice from that point on?
Answer: When primary care practices oﬀer ﬂu clinics, where the only service the practice provides is a ﬂu shot to patients, it is the kind of immunization service the practice provides that will determine the patient’s status to the practice.
CPT® codes 90471-+90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) … and 90473-+90474 Immunization administration by intranasal or oral route … are generally administered by clinical staﬀ such as medical assistants, licensed practical nurses, and registered nurses, rather than physicians or qualiﬁed healthcare professionals (QHPs) (deﬁned by CPT® as “an individual who is qualiﬁed by education, training, licensure/regulation [when applicable], and facility privileging [when applicable] who performs a professional service within his/her scope of practice and independently reports that professional service”).
When immunization services 90471-+90474 are administered by clinical staﬀ, the services do not qualify as professional services (deﬁned by CPT® as “face-to-face services rendered by physicians and other qualiﬁed health care professionals who may report evaluation and management services reported by a speciﬁc CPT® code(s)”). Therefore, the codes do not fulﬁll the requirement for establishing the patient (deﬁned by CPT® as “one who has received any professional services from the physician/qualiﬁed health care professional or another physician/qualiﬁed health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years”) to the physician and/or practice.
Exception: CPT® lists one other immunization administration service: 90460-+90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualiﬁed health care professional …. These services are regarded as professional services because a physician or QHP must counsel the patient or the patient’s caregiver about the vaccination. This means that any patient receiving such services from the same provider or another provider in the same specialty in a group practice within a three-year period must be regarded as established to the practice.
Question 2: Can vaccine administration be reported separately from other services?
Answer: Per CPT® guidelines, if the provider performs a “signiﬁcant separately identiﬁable” evaluation and management (E/M) service, “the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes.”
If vaccine administration occurs on the same date of service as an E/M service, however, append modiﬁer 25 Signiﬁcant, Separately identiﬁable evaluation and management service by the same physician or other qualiﬁed health care professional on the same day of the procedure or other service to the E/M code. Otherwise, payers following National Correct Coding Initiative (NCCI) edits will bundle payment for the E/M code into the vaccine administration code(s).
Exception: Per NCCI, 90460 cannot be billed in conjunction with 90471-+90474, and no modiﬁer is permitted with any of these code pairs. If billed together, only 90460 will be paid. Also, per NCCI edits, 99211 is a component code of 90460-+90461 and 90471-+90474, and no modiﬁer is permitted with this code pair, as well. Only the vaccine administration code, not 99211, would be paid.
Question 3: In encounters where a provider administers diﬀerent vaccine routes, do I report the base vaccine codes for each route?
Answer: The descriptors for both +90472 and +90474 direct you to list the codes separately “in addition to code for primary procedure.” Also, the parenthetical note following both codes indicates you may report these codes in conjunction with any of the base codes. This means only one base code is typically reported, even when diﬀerent routes of administration are involved.