June 1, 2015

One Vaccine Code Fits All?

By

Someone recently asked me an interesting question I had not thought about previously – hence the impetus to write this article. The question was “why code immunization to Z23 in ICD-10-CM?”

I did some research, and below is an excerpt from the ICD-9-CM/ICD-10-CM/PCS Coordination and Maintenance Committee Meeting Summary of Diagnosis Presentations from Sept. 18-19, 2013.

 

Dr. James Nagel with the Upper Chesapeake Medical Center commented that he supports adding in more specificity for these vaccinations. He also suggested seeking input from the Advisory Committee on Immunization Practices (ACIP) regarding recommendations on certain vaccines and if others should be added. Specifically, he recommended considering codes for vaccines for rotavirus and meningococcal disease. Darlene Hyman, also of Upper Chesapeake Medical Center, indicated that she prefers to just have one code for the vaccine and then code the specific type of vaccine using a procedure code. She agreed with using a code for an encounter in which a RhoGam injection was given.

Another healthcare professional, Donna Picket, indicated that there are philosophical issues regarding how much detail a disease classification should have about what appears to be procedures. She invited participants to submit comments on these issues. Sue Bowman with the American Health Information Management Association (AHIMA) recommended changing the Excludes1 notes for these codes so that one could code multiple encounters for vaccination codes together when needed (for example, an MMR vaccine given at the same time as a separate tetanus vaccine).

Nelly Leon-Chisen with the American Hospital Association (AHA) recommended further review of the Hemophilus influenzae type B and whether that code is too specific. Becky Dolan with the American Academy of Pediatrics (AAP) commented that the intent with this proposal was to retain one code for encounters for routine vaccines but to have separate codes for vaccines that are given in other types of settings or for non-routine reasons. Examples of these included giving a tetanus vaccine in an inpatient setting or a rabies vaccine (which is not routinely given to everyone). They did not intend to have all of the ICD-9-CM prophylactic vaccine codes carried over to ICD-10-CM and indicated that their members actually do prefer having one code for routine vaccines.

http://www.cdc.gov/nchs/data/icd/icd_summary_sept_181913.pdf

In the 2015 ICD-10-CM draft, we still encounter that code Z23 applies to all vaccinations.

This code is used for the description synonyms below:

  • Bacterial disease vaccination given
  • Bacterial disease vaccination given (situation)
  • Diphtheria and tetanus vaccination given
  • Diphtheria and tetanus vaccination given (situation)
  • Diphtheria, tetanus and acellular pertussis vaccination given
  • Diphtheria, tetanus and acellular pertussis vaccination given (situation)
  • Diphtheria, tetanus, acellular pertussis, haemophilus influenzae B and inactivated polio vaccinations given
  • Diphtheria, tetanus, acellular pertussis, haemophilus influenzae B and inactivated polio vaccinations given (situation)
  • Diphtheria, tetanus, acellular pertussis, hepatitis B and inactivated polio vaccinations given
  • Diphtheria, tetanus, acellular pertussis, hepatitis B and inactivated polio vaccinations given (situation)
  • Diphtheria, tetanus, pertussis and polio vaccination given
  • Diphtheria, tetanus, pertussis and polio vaccination given (situation)
  • Haemophilus influenzae type b vaccination
  • Haemophilus influenzae type b vaccination (procedure)
  • Herpes zoster vaccination given
  • Herpes zoster vaccination given (situation)
  • Human papilloma virus vaccination given
  • Human papilloma virus vaccination given (situation)
  • Influenza vaccination given
  • Influenza vaccination given (situation)
  • Measles, mumps and rubella vaccination given
  • Measles, mumps and rubella vaccination given (situation)
  • Meningococcal vaccination given
  • Meningococcal vaccination given (situation)
  • Pneumococcal 13-valent conjugate vaccination given
  • Pneumococcal 13-valent conjugate vaccination given (situation)
  • Pneumococcal 23-valent polysaccharide vaccination given
  • Pneumococcal 23-valent polysaccharide vaccination given (situation)
  • Vaccination for bacterial disease
  • Vaccination for diphtheria, tetanus and acellular pertussis
  • Vaccination for diphtheria, tetanus and acellular pertussis (DTaP)
  • Vaccination for diphtheria, tetanus, acellular pertussis, haemophilus influenzae type B and polio
  • Vaccination for diphtheria, tetanus, pertussis, and polio
  • Vaccination for haemophilus influenzae type B
  • Vaccination for herpes zoster
  • Vaccination for HPV
  • Vaccination for human papilloma virus (HPV)
  • Vaccination for influenza
  • Vaccination for measles, mumps and rubella
  • Vaccination for measles, mumps and rubella (MMR)
  • Vaccination for meningococcus
  • Vaccination for strep pneumonia w pneumovax
  • Vaccination for strep pneumonia w Prevnar 13
  • Vaccination for Streptococcus pneumoniae with pneumovax
  • Vaccination for Streptococcus pneumoniae with Prevnar 13
  • Vaccination for tetanus and diphtheria
  • Vaccination for tetanus, diphtheria, acellular pertussis, hepatitis B and polio
  • Vaccination for varicella
  • Vaccination for varicella (chicken pox)
  • Vaccination for viral hepatitis
  • Vaccination for yellow fever
  • Vaccination w combination vaccine
  • Vaccination with combination vaccine
  • Vaccination with combination vaccine done
  • Vaccination with combination vaccine done (situation)
  • Varicella vaccination
  • Varicella vaccination (procedure)
  • Viral hepatitis vaccination given
  • Viral hepatitis vaccination given (situation)
  • Yellow fever vaccination given
  • Yellow fever vaccination given (situation)

Procedure codes are required to identify the types of immunization. Unlike in CPT, the PCS procedure codes are not specific as to the type of toxoid or vaccine that is being administered.


In CPT DTaP administered to a 6-year-old child would be coded as 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP); when administered to a child younger than seven years, for intramuscular use, it is coded to 90471 Immunization administration (including percutaneous, subcutaneous, intramuscular, or jet injections). This is for one vaccine (single or combination vaccine/toxoid). The PCS code for DTaP is 3E0234Z, which captures the body system/region 2 for intramuscular administration but does not capture the specific drug.

Example: A 50-year-old patient presents for an office visit for ongoing monitoring and evaluation of her diabetes, and during this visit, Fluvirin (influenza vaccine) is administered. The physician might report code 99213-25 with diagnosis code E11.9, Type II diabetes without complications.* In addition, he or she would also report Z23 encounter for immunization and the appropriate flu vaccine 90656 and administration 90471 codes.

However, this same patient in the inpatient setting, admitted with exacerbation of asthma and history of diabetes, if given Fluvirin would be coded as J45.901 unspecified asthma with (acute) exacerbation, E11.9 Type II diabetes without complications, and Z23 encounter for immunization with the addition of the PCS code for the administration vaccine 3E0234Z introduction of vaccine, serum or toxoid into muscle . However, in the inpatient setting a reviewer/data analyst cannot determine from codes Z23 and 3E0234Z that the patient was given an influenza vaccine. In ICD-9 we would code the influenza vaccine to V04.81, Need for prophylactic vaccination and inoculation against influenza, and 99.29, Injection or infusion of other therapeutic or prophylactic substance. If ICD-10 is designed to give greater code specificity, would it not be warranted to either specify the type of immunization or the type of vaccine by expanding the qualifier (seventh character)?

 

*If the type of diabetes mellitus is not documented in the medical record, the default is E11., Type 2 diabetes mellitus. (ICD-10-CM 2015 Official Guidelines for Coding and Reporting Section I C. 4.a.2, pg. 32).

http://www.cdc.gov/nchs/data/icd/ICD10cmguidelines_2015%209_26_2014.pdf

Denise M. Nash, MD, CCS, CIM

Denise M. Nash, MD, CCS, CIM, serves as vice president of compliance and education for MiraMed Global Services and as such she handles all Compliance and Education needs including migration to ICD-10. She has more than 20 years experience in the healthcare industry. Dr. Nash has worked for CMS in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. She has also worked with individuals as well as physician groups on utilization and PQRS management to improve financial performance for the risk-based contracts and value based purchasing (VPB) programs. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division.

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