Challenges:  Patient Age  Live virus or split virus  Preservative free or with preservative  Combo vaccine or individual vaccine  Route of administration  Appropriate administration codes With or without counseling Route of administration (intramuscular, oral, intranasal) Number of vaccines or components given  State vs. provider supplied vaccines  Insurance billing requirements. Administration codes and modifiers.

Some vaccines are coded based on specified age ranges while others are not Example: 90634Hep A, pediatric/adolescent dosage, 3 dose schedule 90655Influenza, ……… children 6 – 35 months of age 90714Tetanus and diphtheria toxoids …..7 years or older 90707Measles, mumps and rubella, live, for subcutaneous use

It is important to know the qualities of the vaccine being provided as this can change the CPT code  “with preservative” or “preservative free”  Live virus or split virus  Trivalent or Quadrivalent (Influenza vaccines)  7 Valent or 13 Valent (Pneumococcal) Example: – Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6 – 35 months of age, for intramuscular use – Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children months of age, for intramuscular use.

The vaccine codes range from CPT – New Codes for 2015: – Human Pappillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, non-valent (HPV), 3 dose schedule, for intramuscular use – Influenza virus vaccine, quadrivalent, (IIV4), split virus, preservative free, for intradermal use

Vaccine administration codes are broken down into three categories: 1. Vaccines without Counseling ( ) 2. Vaccines with Counseling (90460 – 90461) 3. Vaccines for Medicare (G0008, G0009, G0010)

Most vaccines are given as intramuscular or subcutaneous injections and are reported using administration codes  Initial vaccine  Subsequent vaccines However, there are a few oral and intranasal vaccines that are reported using administration codes  Initial vaccine  Subsequent vaccines

If one or more vaccines are performed during an encounter specify an initial administration code first.  · – Immunization administration for percutaneous, intradermal, subcutaneous or intramuscular injections, initial  · – Immunization administration for intranasal or oral route, initial Only one initial administration code should be listed per encounter. When both injectable and oral/intranasal vaccines are performed during the same visit, report as the initial administration code.

If more than one vaccine is administered on the same day, a second or third administration fee is required to document the additional vaccines. All subsequent vaccine codes are classified as add-on codes and must never be reported without an initial administration code (90471 or 90473). The definitions for the subsequent administration codes are as follows:  · – Immunization administration for percutaneous, intradermal, subcutaneous or intramuscular injections, each additional vaccine  · – Immunization administration for intranasal or oral route, each additional vaccine When three or more vaccines are performed during an encounter, apply units to the subsequent administration code for each additional vaccine of the same type (injectable or oral).

5 Injectable Vaccines:  x1 unit (Initial)  x4 units (Subsequent) 1 Intranasal, 2 Oral Vaccines:  x1 unit (Initial)  x2 units (Subsequent) 4 Injectable & 1 Oral Vaccine:  x1 unit (Initial)  x3 units (Subsequent)  x 1 unit (Subsequent)

Pediatric immunization administration codes:  90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component  : Each additional vaccine/toxoid component (list separately in addition to code for primary procedure) Report multiple units of code for each first vaccine/toxoid component administered. No modifier should be required when reporting multiple first components. Note also that code does not apply only to combination vaccines, but also to single component vaccines (such as influenza, human papilloma virus, or pneumococcal conjugate vaccines). The base code is reported for each vaccine administration to patients 18 years of age and under who receive counseling about the vaccine from a physician or qualified health care professional at the time of administration. Code is an add-on code reported for each additional vaccine component administered. For example: MMR (Measles, Mumps and Rubella). How would you code the administration of this vaccine? Answer: 90460, x 2

Diphtheria and Tetanus Toxoids Adsorbed DT (pediatric)290460, V06.5 Tripedia®DTaP390460, 90461, V06.1 INFANRIX® DTaP390460, 90461, V06.1 DAPTACEL®DTaP, 5 Pertussis antigens390460, 90461, V06.1 PEDIARIX®DTaP-Hep B-IPV590460, 90461, 90461, 90461, V06.8 TriHIBit®DTaP-Hib490460, 90461, 90461, V06.8 Pentacel®DTaP-Hib-IPV590460, 90461, 90461, 90461, V06.8 KINRIX™DTaP-IPV490460, 90461, 90461, V06.3 HAVRIX®DTP390460, 90461, V06.1 VAQTA®Hep A, adult V05.3 HAVRIX®Hep A, adult V05.3 VAQTA®Hep A, ped/adol, 2 dose V05.3 HAVRIX®Hep A, ped/adol, 2 dose V05.3 Twinrix®Hep A, ped/adol, 3 dose V05.3 RECOMBIVAX HB®Hep A-Hep B290460, V05.3 ENERGIX-B® Hep B, adolescent or pediatric V05.3 RECOMBIVAX HB® Hep B, adolescent or pediatric V05.3 RECOMBIVAX HB®Hep B, adult V05.3 ENERGIX-B®Hep B, adult V05.3

An 11-year old girl presents for a preventive visit (99393). In addition, the child and her mother are counseled by the physician on risks and benefits of HPV (90649), Tdap (90715) and seasonal influenza (90660) vaccines. The mother signs consent to administration of these vaccines. A nurse prepares and administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is no immediate adverse reaction. CPT Codes reported are: Preventive service HPV vaccine Administration first component (1 unit) Tdap vaccine Administration first component (1 unit) additional components (2 units) Influenza vaccine, live, for intranasal use Administration first component (1 unit)

Standards set by the National Childhood Vaccine Injury Act (NCVIA) - Enacted in 1986 Vaccines covered include diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), varicella, seasonal influenza (inactivated and live attenuated), pneumococcal conjugate, meningococcal, rotavirus, and human papillomavirus (HPV) vaccine. 1) Vaccine Manufacturer 2) Lot number of the vaccine 3) Date of administration 4) Name, office address and title of healthcare provider administering the vaccine 5) Vaccine Information Sheet (VIS) edition date provided for each vaccine 6) Date VIS is provided to the patient, parent, or guardian.

Medicare currently only covers 2 vaccines under Part B for preventative:  Influenza (the flu);  The seasonal flu shot currently includes both a seasonal flu shot and an H1N1 (swine flu) vaccination.  Pneumonia;  There are two separate, different doses of the pneumonia vaccine that are provided at least a year apart;  Hep B – High Risk criteria must be met Vaccines covered based on diagnosis:  Diptheria/Tetanus (DT) – Injury only All other commercially available vaccines are covered under Medicare Part D if the patient has this benefit. Administration coding: G0008 – Administration of influenza virus vaccine G0009 – Administration of pneumococcal vaccine G0010 – Administration of Hepatitis B vaccine

When vaccines are provided as part of a well- child encounter, the ICD-9 guidelines instruct that code V20.2 (routine infant or child health check) includes immunizations appropriate to the patient's age. A code from categories V03- V06 may be used as a secondary code if the vaccine is given as part of a preventive health care service, such as a well-child visit. What does the payer want??

The Vaccines for Children (VFC) program is a federally funded program that:  Provides vaccines at no cost to children (age 0 to 18) who might not otherwise be vaccinated due to the inability to pay.  Allows providers to charge a vaccine administration fee based on the Centers for Medicare and Medicaid regional vaccine administration fee cap rates.

As Providers of VFC vaccines we have a responsibility to screen for VFC eligibility and document eligibility status. Screening to determine VFC eligibility and documenting the current VFC eligibility status must take place at each immunization visit for all patients birth through 18 years of age. Screening results must be documented at each immunization visit even if there is no change in eligibility status. The only factors that can be considered when screening for VFC-eligibility are age and whether the child meets the definition of at least one of the following categories: Medicaid eligible, uninsured, American Indian/Alaska Native, and underinsured.

VFC eligibility categories Children birth through 18 years of age who meet at least one of the following criteria are eligible to receive VFC vaccine:  Medicaid-eligible: A child who is eligible for the Medicaid Program. For the purposes of the VFC program, the terms "Medicaid-eligible" and "Medicaid-enrolled" are equivalent and refer to children who have health insurance covered by a state Medicaid program  Uninsured: A child who has no health insurance coverage  American Indian or Alaska Native: A child who meets the definition as defined by the Indian Health Care Improvement Act (25 U.S.C. 1603)  Underinsured: A child who has health insurance, but the coverage does not include vaccines; a child whose insurance covers only selected vaccines (VFC-eligible for non-covered vaccines only).

VFC Vaccine must be provided at no cost. Patients, Medicaid agencies, and third party payers cannot be billed for the cost of VFC vaccine.

VFC providers can charge a vaccine administration fee. The administration fee is per vaccine and not per antigen within the vaccine (combination vaccines).  For non-Medicaid, VFC-eligible children (American Indian/Alaska Native, uninsured, underinsured), VFC providers cannot charge the eligible child’s parent/legal guardian a vaccine administration fee that exceeds the maximum regional charge determined by the Centers for Medicaid and Medicare Services.  For Medicaid VFC-eligible children, VFC providers must accept the reimbursement for immunization administration set by the state Medicaid agency or the contracted Medicaid health plans. Contact your local immunization program to check the maximum vaccine administration fee.

VFC providers cannot deny administration of a federally purchased vaccine to an established VFC-eligible patient because the child's parent/guardian/individual of record is unable to pay the vaccine administration fee. The only fee that must be waived is the vaccine administration fee. Other visit or office fees may be charged as applicable.

Guidance can be found on the Washington Vaccine Associations website:

There are many regulations related to being a supplier of VFC vaccines. If your office is providing these services I would recommend that you use the following link to educate yourself and/or your team on these requirements: urses/vfc/10000.asp?student_idhttp://www2a.cdc.gov/nip/isd/ycts/mod1/co urses/vfc/10000.asp?student_id=

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