If you are a pediatrician that provides vaccination counseling for patients under 18 years of age and younger then this blog post is for you!
The following is a clarification on the proper coding and billing for or provider reimbursement for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.
This reimbursement policy applies to Medicaid members (Empire BCBS).
Note: Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)
The following is the correct CPT code with the ICD-10 code that the providers would use in order to get proper reimbursement.
| CPT® code | Fee | Notes | |
| Claims based | CPT 99401DX: Z71.85 | $12.50 | A provider submitting professional claims should bill Current Procedure Terminology (CPT) code 99401 for preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required and recommended for ages 18 years or younger. |
Documentation requirements: In order to get paid for the above mentioned code, the providers need to document the following in either the medical record or a pharmacy record.
- CPT 99402: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure).
- Providers should bill CPT 99402 with ICD-10 code Z71.85.
- Confirm vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible.
- Providers are encouraged to counsel all members who have not already have an appointment scheduled to receive the vaccine dose for which they are being counseled.
- For more information, visit https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
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