Keeping Your Chargemaster Updated is More Important Than Ever
With the recent legislation around price transparency for healthcare providers and insurers, the importance of maintaining your charge description...
1 min read
Deb Kenney : Jan 10, 2023 2:52:03 PM
Part 1 – When a “Problem” is Discovered During Preventive Medicine Encounter
Part 2 – ICD-10-CM Coding in Preventive Medicine
Part 3 – Pediatric Preventive Medicine – Vaccine Administration
This is the third and final article in our three-part series addressing coding challenges associated with preventive medicine services.
Vaccine administration is among the services commonly associated with preventive medicine encounters. However, when it comes to documentation, there are often deficiencies, particularly in our pediatric practices and specifically when reporting CPT® codes 90460 and 90461.
90460 – Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
90461 – Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)
When it comes to administering vaccines to pediatric patients through 18 years of age, our audits have found some common pain points related to the documentation of those administrations.
You can ensure your medical records have sufficient documentation when reporting 90460 and 90461 without it being onerous. The documentation should include:
A sample statement: “I personally performed face-to-face vaccine counseling of all vaccine components administered today. Parent’s questions were answered, and common side effects were discussed. Recommended use of OTC pain relievers, such as ibuprofen if the patient experiences pain at the injection site.”
At The Rybar Group, our experienced and knowledgeable audit team can provide customized, value-added services to meet your compliance program requirements. Our comprehensive documentation and coding audit services are performed in a creative, constructive, and efficient manner, offering education tailored to your practice. Contact us today to inquire about our chart auditing and provider education services.
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