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2019 Immunization Coding for Obstetrician-Gynecologists

Coding Case Examples

Case 1        

A 65-year-old woman comes in for her annual check-up. She also requests a flu vaccine. The patient has Medicare. The appropriate physical examination is performed, and a Pap test specimen is collected because of her risk factors.

Comment

Medicare allows coverage for a pelvic examination every 2 years, but for certain high- risk patients it is covered annually. Collection of a Pap specimen is also a reimbursable service at the time of these encounters. Other services (eg, vaccines) also may be per- formed during these encounters and should be coded and billed separately. Medicare requires specific HCPCS codes for these services. The appropriate procedure codes and ICD-10-CM linkages are listed as follows:

  • G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination
  • Z01.419 Encounter for gynecologic examination (general) (routine) without abnormal findings
  • Q0091 Collection of screening Pap smear
  • Z01.419 Encounter for gynecologic examination (general) (routine) without abnormal findings
  • 90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
  • Z23 Encounter for immunization
  • G0008 Influenza vaccine administration
  • Z23 Encounter for immunization

Case 2 

A 15-year-old new patient is brought to the office by her mother. The patient and her mother want to talk about a variety of topics, including reproductive health, birth con- trol options, and vaccinations. The appropriate history is obtained. A physical exam- ination limited to the head, chest, abdomen, and extremities is performed. Questions are answered, and the appropriate counseling is given. The physician then administers an influenza vaccine, a Tdap vaccine, and the first of the series of three HPV vaccines.

Comment

This encounter is an example of the initial reproductive health visit recommended by ACOG. This encounter should be coded using the preventive medicine codes. The comprehensive nature of preventive medicine codes reflects an age-appropriate and gender-appropriate history or examination, or both, and is not synonymous with the comprehensive examination required in other E/M codes. There are no CPT guidelines stating what is included in a preventive visit, and it will vary with the needs of each patient. In this case, a pelvic examination and breast examination were not necessary. Nevertheless, this encounter is reported as a preventive visit. Other services may be provided at the time of these types of encounters and should be coded and billed sepa- rately. The appropriate procedure codes and ICD-10-CM linkages are listed as follows:

  • 99384 Initial comprehensive preventive medicine adolescent (12–17 years)
  • Z01.419 Encounter for gynecologic examination (general) (routine) without abnormal findings
  • 90651 Human papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2-dose or 3-dose schedule, for intramuscular use
  • Z23 Encounter for immunization
  • 90460 Vaccine administration
  • Z23 Encounter for immunization
  • 90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
  • Z23 Encounter for immunization
  • 90460 Vaccine administration
  • Z23 Encounter for immunization
  • 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use
  • Z23 Encounter for immunization
  • 90460 Vaccine administration
  • +90461 Additional vaccine component
  • +90461 Additional vaccine component

Case 3 

A 34-year-old established patient requests assistance in obtaining a hepatitis B vaccine. Her insurance plan requires her to obtain the vaccine product from her local pharmacy. She brings the appropriately stored vaccine to the office. The office nurse sees the patient, checks her blood pressure, obtains appropriate informed consent documents, and admin- isters the hepatitis B vaccine.

Comment

This example describes a situation in which the only service provided in the office is the vaccine administration. The services provided by the nurse are integral to the vaccine administration code. A separate E/M service was not provided in this situation. Because the patient brought the vaccine product with her, it is not appropriate to bill for the vaccine product. The appropriate procedure code and ICD-10-CM linkage are listed as follows:

  • Z23 Encounter for immunization
  • 90471 Vaccine administration

NOTE: Some third-party payers deny payment for the vaccine administration codes (90471 and +90472) provided on the same day as a separate and distinct E/M service. It is important to track and appeal such denials because they are in conflict with CPT coding guidelines and standard payment conventions.

Case 4 

A 21-year-old established patient comes in for her wellness examination. She has ques- tions about the HPV vaccine. In addition to the usual age-appropriate history, counsel- ing, comprehensive physical examination, and Pap test, the patient is given information regarding the requested vaccine. Her questions are answered, and she requests that the first of the series of three vaccinations be given.

Comment

This example illustrates the additional counseling that will be necessary as new vacci- nations become available. The additional work involved with this counseling is integral to the preventive medicine visit and not reported separately. The appropriate procedure codes and ICD-10-CM linkages are listed as follows:

  • 99395 Periodic comprehensive preventive medicine 18–39 years
  • Z01.419 Encounter for gynecologic examination (general) (routine) without abnormal findings
  • 90651 Human papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2- or 3-dose schedule, for intramuscular use
  • Z23 Encounter for immunization
  • 90471 Vaccine administration
  • Z23 Encounter for immunization

Case 5 

The 21-year-old established patient referenced in Case 4 returns to the clinic in 2 months for the second of her series of three HPV vaccines. She also reports dysuria. The office nurse checks her blood pressure, completes the appropriate vaccine informed consent documents, and orders a urinalysis. The urinalysis result is normal. The nurse admin- isters the HPV vaccine, documents the encounter in the medical record, and asks the patient to make a follow-up appointment with her physician to further assess her report of dysuria.

Comment

This example illustrates an encounter in which the nurse provides a separate E/M ser- vice distinct from the vaccine administration service. Some vaccines require a mutidose regimen. It is appropriate to use the same vaccine product code for each of the three injections. Modifier 25 is appended to the E/M encounter to signify the distinct and separate service. The appropriate procedure codes and ICD-10-CM linkages are listed as follows:

  • 99211–25 Office outpatient visit (nursing encounter)
  • R30.0 Dysuria
  • 81000 Urinalysis
  • R30.0 Dysuria
  • 90651 Human papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2- or 3-dose schedule, for intramuscular use
  • Z23 Encounter for immunization
  • 90471 Vaccine administration
  • Z23 Encounter for immunization

Case 6

A 28-year-old new patient presents with primary dysmenorrhea. She also requests an influenza vaccine. A detailed history is taken, and a detailed physical examination is performed. The medical decision making is of low complexity. The patient is given information regarding the influenza vaccine and the vaccine is administered by the office nurse.

Comment

Patients sometimes will request vaccine services at the time of a problem-oriented visit. It is appropriate to code and bill for the vaccine administration and vaccine product as well as for the E/M service. If counseling is extensive and accounts for more than 50% of the total time spent with the patient, it may be appropriate to code based on time rather than the usual key components of history, physical examination, and medical decision making. The appropriate procedure codes and ICD-10-CM linkages are listed as follows:

  • 99203–25 Office outpatient visit new patient
  • N94.4 Primary dysmenorrhea
  • 90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL, for intramuscular use
  • Z23 Encounter for immunization
  • 90471 Vaccine administration
  • Z23 Encounter for immunization

Case 7 

A 25-year-old nulligravid patient is receiving prenatal care in the office. At 12 weeks of gestation, an influenza vaccination is administered.

Comment

Pregnant patients will request, and in some instances require, vaccinations during their pregnancies. Vaccination services performed during pregnancy should be billed sep- arately at the time of the service. If a patient has any additional conditions that might put her at high risk of influenza, report a secondary code for the high-risk condition.

This process will facilitate payment from plans that only cover vaccinations for patients identified as high-risk patients. A separate E/M service should not be reported because the office visit is part of the global obstetric package. The appropriate procedure codes and ICD-10-CM linkages are listed as follows:

  • 90656 Preservative-free influenza vaccine (trivalent) (drug), for intramuscular use

Or

  • 90686 Influenza vaccine (quadrivalent), for intramuscular use Or
  • 90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
  • Z23 Encounter for immunization
  • 90471 Vaccine administration
  • Z23 Encounter for immunization
  • Z34.01 Encounter for supervision of normal first pregnancy, first trimester
  • Z3A.12 12 weeks of gestation (optional)

Case 8 

The patient referenced in Case 7 comes in for a routine appointment at 28 weeks of gestation. She is Rh negative and is given antenatal Rho(D) immune globulin. She also receives her Tdap vaccination.

Comment

It is appropriate to code and bill for the Rho(D) immune globulin administration out- side of the global obstetric package. Some payers may require the use of special HCPCS codes (“J” codes) to identify the Rho(D) immune globulin product. Also, note that the CPT codes for administration of Rho(D) immune globulin are different than those used for administration of vaccines. The appropriate procedure codes and ICD-10-CM link- ages are listed as follows:

  • 0384 Rho(D) immune globulin (RhIg), full dose (drug), for intramuscular use

Or

  • J2790 Injection, Rho(D) immune globulin, human, full dose, 300 micrograms (1,500 international units) 
  • 96372 Injection (therapeutic, prophylactic, or diagnostic), for subcutaneous or intramuscular use
  • 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use
  • Z23 Encounter for immunization
  • 90471 Vaccine administration
  • Z23 Encounter for immunization
  • Z34.03 Encounter for supervision of normal first pregnancy, third trimester
  • Z3A.28 28 weeks of gestation (optional)

Case 9 

The patient referenced in Case 7 and Case 8 is now 6 weeks in the postpartum period. On her antenatal screening, her rubella titer result was negative. She is given a mea- sles–mumps–rubella (MMR) vaccination.

Comment

The postpartum visit often will require vaccination services. These services should be coded and billed outside the global obstetric package. A separate E/M service should not be reported because the 6-week postpartum visit is part of the global obstetric pack- age. The appropriate procedure codes and ICD-10-CM linkages are listed as follows:

  • 90707 Measles–mumps–rubella virus vaccine (MMR), live, for subcutaneous use
  • Z23 Encounter for immunization
  • 90471 Vaccine administration
  • Z39.2 Encounter for routine postpartum follow-up