Auditing Vaccines

by  Paul Chandler
Jul 28th, 2017 - Reviewed/Updated Jan 31st

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.