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Reimbursement Advisor


How do we code for new HPV vaccine?

July 2006 · Vol. 18, No. 7

<huc>Q</huc> When we start giving the new HPV vaccine, how do we bill for it?

<huc>A</huc> On June 8, 2006, the Food and Drug Administration (FDA) officially licensed the HPV vaccine for use in girls and women ages 9 to 26.

  • 90649 is the vaccine product code (human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use). A 3-dose schedule means you will be billing for the procedure 3 times during a 6-month period.
  • 90471 can also be reported for the administration of the vaccine. (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid])

Adding modifiers. CPT guidelines state that a modifier -51 (multiple procedure) would not be added to either of these codes, and of course if you provide a significant and separate evaluation and management (E/M) service at the time the vaccine is given, you may also bill an E/M code with a modifier -25 added to let the payer know that the E/M service was separate.

Note that almost no payers will pay separately for the E/M code 99211 plus an injection procedure because it represents a minimal, not a significant E/M service.

Insurance coverage unlikely, for now

Until such time as the CDC comes out with a recommendation for the vaccine, coverage is going to be a problem. Insurance plans can be expected to cover the cost of the vaccine only if the CDC Advisory Committee on Immunization Practices recommends HPV vaccination as standard.

Tell patients! Until then, you may want to advise your patients who are candidates for the vaccine that this vaccine may be an out-of-pocket expense for them. Merck, the company that produces the quadrivalent vaccine, has stated that the price will be $120 per injection. The company has indicated that they have created a new program to provide free vaccines including HPV vaccine, for uninsured adults unable to pay.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

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