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Modifier Coding Alert

Reader Questions:

Break Out 25 When Counseling Leads To Vaccination

Question: An established 19-year-old patient reported to our family physician for counseling on administration of the human papillomavirus (HPV) vaccine. Notes indicate that the physician spent 27 minutes discussing risks, benefits, and potential side effects of the vaccine. After the counseling, the patient decided to get the vaccination, which our physician provided during the same encounter. Can we code for the vaccination and the counseling separately, or is the counseling included in the work units for the vaccination?

Connecticut Subscriber

Answer: Since the counseling prompted the patient to go ahead with the vaccination, you should be able to report it separately. On the claim, you should report 99402 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to individual in a group setting [separate procedure]; approximately 30 minutes) for the counseling. Then, report 90649 (Human Papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3 dose schedule, for intramuscular use) for the vaccine supply and 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) for the vaccine administration. Check with your local payers to make certain they will recognize the code that is supported by the documentation in the chart.

Modifier alert: The vaccine administration and the counseling occurred on the same date, which might lead your payer to believe you are miscoding. To clear up any confusion, attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99402 to show that the counseling and the vaccination were clearly separate services.

Exception: If the patient had reported for a scheduled HPV vaccine administration, then you could not code separately for the counseling. In your scenario, the counseling leads to the vaccination, meaning that the counseling was a separate service from the vaccination. Also, you’d be well-served to ask your provider to include a note in the documentation with words to the effect of: “Patient reported for HPV vaccine counseling, and decided to have vaccination during that encounter” for these types of encounters.

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