Pediatric Preventive Medicine – Vaccine Administration

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.

• Documentation does not support that vaccine counseling was performed. Vaccine Information Statements (VIS) are not the same as counseling.
• If documentation supports vaccine counseling was performed, it often doesn’t specify who provided the counseling. Medical assistants or other clinical staff members (e.g., LPNs, RNs) providing vaccine counseling do not meet the requirements of codes 90460 and 90461.
• Documentation does not support that counseling was provided for all vaccine components administered. A component refers to all antigens in a vaccine that prevent diseases caused by one (1) organism. Combination vaccines are vaccines that contain multiple vaccine components.

You can ensure your medical records have sufficient documentation when reporting 90460 and 90461 without it being onerous. The documentation should include:

• A statement that vaccine counseling was provided and performed by the physician or other qualified health care professional.
• Include notation that counseling was completed for all vaccine components administered.

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.