July 2017

Coding Corner: Vaccination Sticking Points
By Barbara A. Taylor, RHIA
For The Record
Vol. 29 No. 7 P. 28

Vaccinations are not only for children. For adults, many childhood vaccinations may have worn off and no longer provide the necessary protection. Also, new vaccines emerge over the years.

While the adult population is concerned about children receiving the necessary immunizations, many forget about themselves.

According to the Centers for Disease Control and Prevention (CDC), in 2014 only 35.8% of adults ages 18 to 64 received an influenza vaccination in the past 12 months compared with a rate of 69.1% for those older than 65. Adults in the latter category received a pneumococcal vaccination at the rate of 63.5%. In the population of children 19 to 35 months old, 71.6% received combined vaccinations. These included diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, Haemophilus influenzae type b, hepatitis B, chickenpox, and pneumococcal conjugate vaccine.

Recommended vaccinations for children begin at birth with their first dose of hepatitis B. During the first 15 months, they should receive more than 20 vaccinations. Many parents decide not to have their children vaccinated despite a child's immune system being more vulnerable without vaccinations. A child who has not been vaccinated can become seriously ill or even die from measles, mumps, or whooping cough.

The CDC recommends adults receive a diphtheria, tetanus, and pertussis vaccination every 10 years. The agency also suggests adults receive the shingles vaccine even if they have previously contracted the virus. Other vaccinations for adults include rubella, HPV (human papillomavirus), hepatitis A or B, and pneumococcus.

Inoculations and Vaccinations ICD-10-CM Coding
Code Z23, which is used to identify encounters for inoculations and vaccinations, indicates that a patient is being seen to receive a prophylactic inoculation against a disease. If the immunization is given during a routine preventive health care examination, Code Z23 would be a secondary code. The routine examination, such as a well-baby visit, would be entered first.

There will be times when a vaccination has been ordered and then not given. In those instances, the reason it was not given needs to be coded. If a patient is underimmunized, a code should be added.

Several types of situations warrant a vaccination not be administered. For example, if there is a contraindication, it could be withheld. Other instances include the following:

• Z28.01 Immunization not carried out because of acute illness of patient;
• Z28.02 Immunization not carried out because of a chronic illness or condition of patient; and
• Z28.03 Immunization not carried out because of immune compromised state of patient.

A patient could decide not to receive the immunization for reasons of belief or group pressure, including religious belief. Under these circumstances, code Z28.1 would be used.

If a patient declines the immunization for another reason or does not give a reason, one of the following codes would be used:

• Z28.20 Immunization not carried out because of patient decision for unspecified reason;
• Z28.21 Immunization not carried out because of patient refusal; or
• Z28.29 Immunization not carried out because of decision for other reason.

Sometimes a patient is delinquent in immunization status or has a lapsed schedule. In this case, use code Z28.3 Underimmunization.

Additional codes for other reasons an immunization was not administered include the following:

• Z28.81 Immunization not carried out due to patient having had the disease;
• Z28.82 Immunization not carried out because of caregiver refusal; and
• Z28.89 Immunization not carried out for other reason.

There are additional prophylactic codes for immunotherapy such as antivenin—Rho (d) immune globulin, including the following:

• Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus;
• Z29.14 Encounter for prophylactic rabies immune globin; and
• Z29.3 Encounter for prophylactic fluoride administration.

Inoculations and Vaccinations ICD-10-PCS Coding
Procedure codes are required to identify the actual administration of the injection and the type of immunization. PCS codes, which are used when coding an inpatient chart, can be found in Section: 3 (Administration), Body System: E (Physiological Systems and Anatomical Regions), Root Operation: 0 (Introduction).

Immunization is coded 3E0134Z Introduction of Serum, Toxoid and Vaccine into Subcutaneous Tissue, Percutaneous Approach. The body part and approach may change based on the documentation.

Rabies is coded differently in ICD-10-CM than in ICD-9-CM, which featured a separate procedure code for rabies. Now, code 3E0134Z is used for rabies given in subcutaneous tissue with a percutaneous approach. This would also be used for respiratory syncytial virus and other immunizations.

Inoculations and Vaccinations CPT
Immunization administration for vaccines and toxoids is located in the Medicine section of the CPT coding manual. Codes to identify the immune globulins, serum, recombinant products, vaccines, and toxoids are also located in this section. Code vaccine immunization administration 90460, 90471–90474 in addition to toxoid codes 90476–90749.

When a physician or qualified health care professional provides face-to-face counseling to the patient and/or family during the administration of a vaccine, codes 90460 and 90461 are assigned. 90460 is for the initial vaccine administration, while code 90461 is the choice for additional vaccine or toxoid administrated. This would be listed separately in addition to the primary procedure code.

Rabies
Human rabies cases in the United States are rare, with only one to three cases reported annually, according to the CDC. In fact, since 2003, only 34 cases of human rabies have been diagnosed in the United States.

Patients who visit the emergency department (ED) for a series of rabies vaccinations are coded and charged the same as IV series patients. The first ED visit for a rabies injection should result in a charge for the administration and a code level for the facility. For subsequent visits to the ED for an injection of rabies medication, charge only for the administration of the rabies medication. Remember to add modifier -25 to facility level when charging.

Immune Globulins, Serum, and Recombinant Products
Immune serum globulin is a sterile solution of globulins that contains antibodies present in the blood of adults. These products are identified by codes 90281–90399. Modifier 51 should not be reported for this code range. Both the codes and the administration codes should be reported. There may be an immune-globulin, serum, or recombinant that does not have a code. In this case, assign 90399 Unlisted immune-globulin until a code is created for the specific product.

The code description lists the vaccine's route—either subcutaneous or intravenous. The following are examples of these codes:

• 90283 Immune globulin (IgIV), human, for intravenous use;
• 90296 Diphtheria antitoxin, equine, any route; and
• 90389 Tetanus immune globulin (Tig), human, for intramuscular use.

Vaccines and Toxoids
Codes 90476–90749 are used to identify only the vaccine/toxoid product. An administration code must be used with the product code. When vaccine/toxoid codes are reported with administration codes, modifier 51 is not an option.

If an office visit, other outpatient service, or preventive medicine service is performed at the same time the vaccine is given, the appropriate evaluation and management code should be assigned. Remember to assign modifier -25.

When a combination vaccine, such as diphtheria, tetanus, pertussis (DTap-Hepb)/inactivated poliovirus/Haemophilus influenzae type b, is administered, it's inappropriate to code each component of the combination separately.

The following are coding examples for vaccines and toxoids:

• 90710 Measles, mumps, and rubella virus vaccine, live, for subcutaneous use;
• 90736 Zoster (shingles) vaccine, live, for subcutaneous injection; and
• 90747 Hepatitis B vaccine dialysis or immunosuppressed patient dosage, 4 dose schedule, for intramuscular use.

For additional information regarding any codes, refer to ICD-10-CM/PCS and CPT guidelines and coding manuals.

— Barbara A. Taylor, RHIA, is an AHIMA-approved ICD-10-CM/PCS trainer and HIM operations manager at himagine Solutions.