Coding Vaccines - How It's Different

How and why are all vaccines coded differently, and how do you keep up?

If you end up getting a coding position in any kind of family practice, general healthcare, or pediatric setting, chances are that you'll have to code for the vaccines your office administers to patients.

Although vaccine coding is sounds pretty simple (after all, you're only coding for a shot, right?), don't be surprised when you find yourself in a vaccine coding conundrum!

How do you code vaccines?

Coding vaccines involves 3 parts

There are three parts to a vaccine code:

  1. the administration of the vaccine
  2. the vaccine toxoid itself
  3. the vaccine diagnosis code

You code for the nurse giving the patient the shot (the administration), the vaccine serum that goes into the syringe (the stuff that gets injected into the patient), and the diagnosis code for the shot (the reason why the patient received the shot).

So each vaccine has at least three parts, two of which are procedure (CPT) codes:

  • the administration (admin)
  • the toxoid

The last and equally important part of coding vaccines is the diagnosis (ICD-9) code.

Because each procedure code has to be sent with a diagnosis code, vaccine administrations need them as well. Usually these types of codes are sent with a V-code, which indicates that the patient is receiving a vaccine of some sort.

Where does it get complicated?

Sounds easy enough, right? Not so fast!

Each vaccine administration has to be coded in the order in which it was given.

So if the patient was given more than one vaccine, the first vaccine will have a different administration fee than the second vaccine.

If the patient was given more than two vaccines, the coder codes for the first admin fee, then the second admin fee, multiplied by the additional number of shots.

This gets more complicated when you have vaccines that are given differently, but not per location. So in other words, there's a certain administration fee for vaccines that are given subcutaneously and intramuscularly (no matter where the vaccine is given on the body), compared to those given orally or nasally.

This is pretty confusing - let's try and break it down a bit.

Vaccine coding can get complicated!

Let's say we have a pediatric patient coming in for a round of four-year vaccines. The patient will be getting four shots in the office today. Three of them will be given intramuscularly, and the last vaccine will be given nasally.

To code the administrations correctly you'd have to code for:

  • intramuscular admin #1, plus vaccine #1
  • intramuscular admin #2, plus vaccine #2
  • intramuscular admin #3, plus vaccine #3
  • nasal admin #4, plus nasal vaccine #4

Needless to say, only the vaccine coding part of this child's claim would be eight different codes!

Translated to actual codes per current coding guidelines, the real claim would look something more like the following:

  • intramuscular admin #1, vaccine #1
  • intramuscular admin X2 (admins #2 and #3), vaccine #2
  • vaccine #3
  • nasal admin #4, nasal vaccine #4

This may look even more complicated than before, but we actually shortened the claim down from eight different lines to seven. Believe it or not, breaking up the admins and vaccine codes helps the insurance company, nurses, and coders understand which vaccines were given and how.

The correct or incorrect combination of these codes directly affects the payment of vaccine codes, and inputting one wrong admin code may result in a denial of all of your vaccine codes!

This might be helpful in this situation: how to appeal a denied insurance claim.

But it's still not so simple...

Unfortunately, vaccine coding still has many more intricacies.

For instance, CMS (Centers for Medicare and Medicaid Services), which sets many coding standards, developed a new set of vaccine administration codes, which reflect doctor counseling before the vaccines are administered.

This was because of the large numbers of people and parents concerned about the possible health risks or side effects of vaccines.

The new administration codes were developed because doctors spend more time than ever counseling patients on their fear of vaccines. These new codes help reflect the extra time spent, and also try to help doctors get paid for the additional services.

These new codes have really complicated vaccine coding. Now coders have to know whether or not the doctor counseled the patient, as well as how and which vaccine was given.

These vaccine admin counseling codes are too intricate to go into here - some experienced coders are still having trouble understanding them!

The vaccines themselves

You need to know your vaccines in this business! Image copyright National Institutes of Health

In addition to the administration of the vaccines, coders also have to be aware of which vaccines were given.

There are a great many different requirements about which vaccines are necessary at which ages, as well as which type of people are eligible to receive the vaccines, as well as whether or not the patient's insurance will pay for the vaccine.

When coding vaccines, be very careful about which vaccines were given and why, and what insurance the patient has. If certain vaccines are given to the wrong patients, insurance may not pay for them at all.

Updates and changes

To make matters worse, vaccine codes are constantly being updated and changed, depending on changes in vaccines.

For example, during the outbreak of the H1N1 (swine) flu pandemic, new vaccine codes were quickly developed by CMS, the CDC (Centers for Disease Control), and medical supply companies. This was so that doctors could give and get paid for giving the H1N1 flu vaccine in the quickest way possible.

For other, less urgent updates, many vaccine supply companies help spread important vaccine coding updates and new guidelines, as well as the CDC and CMS.

The upshot (no pun intended)

Ultimately, vaccine coding is technically difficult. But once you get the hang of it, it's easy as tying your shoes.

Whether you're just entering the world of coding, or you've been in it for a while, vaccine coding is an important part of understanding the intricate ways that codes affect the treatments that were given, as well as the payments that will be received.

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