Immunizations and Injections
Immunizations and injections, professional services to inject the medications, and the medications that are injected are covered as shown in “Schedule of Benefits and Copayments,” Section 3. This includes allergy serum.
Member Physicians will provide immunizations that are recommended by guidelines published by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Public Health Service or the
American Academy of Pediatrics (AAP).
In addition, injectable medications (including Glucagon) approved by the FDA are covered for the
Medically Necessary treatment of medical conditions when prescribed by the Member’s Primary Care Physician and authorized by Health Net.
Self-injectable Drugs (other than insulin), needles and syringes used with these self-injectable drugs
must be obtained through Health Net’s contracted Specialty Pharmacy Vendor when Prior Authorization is obtained from Health Net. Upon approval, Health Net will arrange for the distribution of drugs, needles and syringes from the appropriate Specialty Pharmacy Vendor. The Specialty Pharmacy Vendor may contact you directly to coordinate the delivery of your medications.
The Specialty Pharmacy Vendor will charge you for the appropriate Copayment or Coinsurance shown in the separate Medicare Prescription Drug Plan Evidence of Coverage.
Reporting Evaluation and Management Services With Immunizations
E/M services most often reported with the vaccine product and immunization administration include new and established patient preventive medicine visits (CPT codes 99381–99395), problem-oriented visits (99201–99215), and preventive medicine counseling services (99401–99404). Any of the aforementioned E/M codes can be reported as a single service or in combination when performed and documented on the same day of service by the same physician or physician of the same group and specialty.
The E/M service must be medically indicated, significant, and separately identifiable from the immunization administration.
• Payers may require modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to be appended to the E/M code to distinguish it from the administration of the vaccine.
• CPT code 99211 (established patient E/M, minimal level, not requiring physician presence) should not be reported when the patient encounter is for vaccination only because the Medicare Resource-Based Relative Value Scale (RBRVS) relative values for the immunization administration codes include administrative and clinical services (ie, greeting the patient, routine vital signs, obtaining a vaccine history, presenting the VIS and responding to routine vaccine questions, preparation and administration of the vaccine, and documentation and observation of the patient following the administration of the vaccine). However, if the service is medically necessary, significant, and separately identifiable, it may be reported with modifier 25 appended to the E/M code (99211). Note that the medical record must clearly state the reason for the visit, brief history, physical examination, assessment and plan, and any other counseling or discussion items. The progress note must be signed with the physician’s countersignature. For more information and clinical vignettes on the appropriate use of code 99211 during immunization administration, visit www.aap.org/pubserv/codingforpeds for a copy of the AAP position paper on reporting 99211 with immunization administration. Payers who do not follow the Medicare RBRVS may allow payment of code 99211 with immunization administration. Know your payer guidelines, and if payment is allowed, make certain that the guidelines are in writing and maintained in your office. Be aware that a co-payment will be required when the “nurse” visit is reported.
• The same guidelines apply to physician visits (99201–99215). In other words, if a patient is seen for the administration of a vaccine only, it is not appropriate to report an E/M visit if it is not medically necessary, significant, and separately identifiable.
• If at the time of a preventive medicine visit a patient has a problem or abnormality that is addressed and requires significant additional work to perform the required key components, a problem-oriented E/M code (99201–99215) may be reported in addition to the preventive medicine services code. There should be separate documentation for the 2 services in the medical record. Typically the level of service is based on the level of history and medical decision-making that are performed and documented because the physical examination component is most often performed as part of the age-appropriate examination included in the preventive medicine service. Modifier 25 must be appended to the problemoriented E/M service to alert the payer that it was significant and separately identifiable. Each code is linked to the appropriate ICD-9-CM code.
Remember that reviewing or discussing the risks and benefits of vaccines and addressing all other patient and parent concerns and questions related to vaccines and immunization administration are included in the immunization administration codes. However, if vaccine counseling is performed and the parent or patient refuses vaccines, the time spent in counseling may be separately reported. Also, if after additional time is spent in vaccine counseling, the parent or patient then decides to accept the immunizations and the time and effort exceeds that normally spent by the physician, it is still appropriate to report these codes in addition to the E/M visit and immunization administration. Make certain that the medical record supports the excess time and effort of counseling.
Teaching Point: Appending modifier 25 to code 99401 and reporting codes V15.83, V06.8, V04.89, V03.82 (need for inoculation against the specific diseases), and V64.05 advise the payer that the vaccine counseling was significant and separate from the preventive medicine visit, the child is behind on his or her immunizations, and the vaccines were refused.
6. A 6-month-old returns for her second hepatitis B vaccine. She did not receive the vaccine during her preventive medicine visit because she was ill. The nurse has documented the following: The patient is here for a missed hepatitis vaccine. Afebrile for 5 days, eating well. Temperature is 98.7°F; active and playful. The risk and potential side effects of the hepatitis vaccine were discussed after the VIS was given and the parent was informed of the correct dosage of an antipyretic medication should fever or fussiness occur afterward.