Immunization Review- Medical Coding

Q: Under what circumstances could this occur? Retrieved from CPT manual “Immunization Administration for Vaccines/Toxoids”. “For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family…”

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A: So, what case do we have that where we don’t have face-to-face physician or professional counseling and when you receive your immunization? As he is bringing up answer sheet, when we talk about immunizations, so typically we know that when you go to the office and you’re getting your immunization and they’re going to say, “Okay, you could have some redness, some swelling especially just for a kid, given them some Tylenol afterwards, maybe if there’s any kind of pain or discomfort for the child.

Under CPT, so I took this directly from CPT. To report the codes 90460, 90461, only when there’s a physician or qualified health care professional and I’m going to abbreviate that instead of to have it typed it every time, providing that face-to-face counseling for the patient or a family member depending upon their age during the administration of the vaccine.

For immunization administration of any vaccine that’s not accompanied by that factor, use the next range of codes. That’s where their question came from. Right under immunization administration for vaccines and toxoids, I think it’s the first or second page in the medicine section, you’re going to see that header for that category and then, this is what it says right after that or administration of vaccines over 18 years of age, I forgot that part, we’re going to report the codes in the range 90471 to 90474.
Then it says at parenthetical, see also the instructions for use of the CPT code book for that definition. Now, you’ve got to flip all the way to the very front of your book. At the very beginning of CPT, there are instructions for how to use CPT. There in those Roman numeral pages.

The third paragraph there says when an advanced practice nurse or physician assistant is working with the physicians, they’re considered working that same specialty or same sub-specialty. So, you have a PA, you have a nurse practitioner, somebody like that in your office, they are working as if they are that same physician. In ours, we have PAs and nurse practitioners, they’re working as orthopedic providers. Same thing in the dermatology or cardiology clinic. These professionals are distinct from clinical staff. Those professionals, a PA or a nurse practitioner, they are working under the scope of their license under the scope of the state qualifications for that type of provider. They are different than clinical staff.

A clinical staff member is a person who works under the supervision of a physician or one of these other qualified health care professionals and who is allowed by law, by regulation and by that facility policy, all three, to perform or assist in the performance of a specified professional service who does not individually report that service. They’re clinical staff member. They are allowed to help based upon if there were an MA certification or some states don’t allow MAs to do certain things but they have a law, a regulation of their society and your facility standards that they can perform certain things, but they don’t bill for them. They don’t do that and a physician doesn’t bill for it either because they’re supervised. They’re not the ones providing that service. They don’t report that service.
Scrolling down a little bit more, we have our two codes that we said, the 90460 and 90461, that’s administration with counseling. That’s the physician and nurse. Somebody says, “Okay, watch out for any redness, swelling. Do you have allergic reaction to eggs?” whatever the case maybe, whatever kind of counseling or information they are providing to the patient. Those are the codes that are going to accompany the vaccine administration. At that time, it’s given by a physician or qualified health professional.

The case where we’re going to use when it’s non-face-to-face is our clinical staff. We have the codes laid out a little bit further down, the 90471 through 90474. It depends on the route of administration as the difference between these two codes. We have intramuscular, subcutaneous, intradermal or we have intranasal or oral. If that’s our clinical staff member providing those services. In immunization either intranasally, orally or intramuscular.