Vaccine counseling services between a healthcare provider and a patient or a parent can include:
- Obtaining information on potential contraindications to receiving a particular vaccine(s)
- Reviewing/discussing the relevant CDC Vaccine Information Statement(s) (VIS)
- Reviewing/discussing risks and benefits of specific vaccine(s)
- Addressing all other patient/family concerns and questions related to vaccines and immunization administration
Billing for vaccine counseling can differ depending on the patient and/or the clinic:
Children
- Counseling must be done by a qualified healthcare provider (physician, nurse practitioner, or physician assistant). Counseling done by a registered nurse cannot be billed.
- Most private payers and Medicaid plans allow billing for vaccine counseling only if the counseled vaccine was administered during the same visit. In this case, billing is performed by antigen for private payers. Number of antigens is not a factor when billing to Medicaid.
- Some payers allow billing for vaccine counseling even if no vaccine was administered during the visit. It is important to take into account that different payers have different criteria for billing, which need to be met and documented.
Resources from the American Academy of Pediatrics (AAP):
- Vaccine Financing and Coding
- Immunization Coding Table
- Vaccine Counseling and Preventive Care Visits
Adults
- Vaccine counseling for adults is not billed as a separate coded item when vaccines are administered. Therefore, there is no CPT code for “vaccine administered after provider counseling” for adults. As of August 14, 2023, the CPT panel has developed a separate administration code for COVID-19 vaccines. More information is available here.
- Billing for vaccine administration in theory includes counseling, however, the administration payment is often insufficient for time spent. If this is the case, counseling time can be added to the encounter code for a “more complicated visit.”
Resources from the National Adult and Influenza Immunization Summit (NAIIS):
- Billing, Coding, and Payment
- Top Questions for Medical Benefit Coding and Billing for Vaccines
- Coding Case Scenarios – on the Billing, Coding, and Payment page, scroll down to Resources for “Adult Current Procedural Terminology: Coding Case Scenarios”
Federally Qualified Health Centers (FQHCs)
- Payment structures and policies in FQHCs pose unique challenges for vaccination of adults. There exist some policy barriers and strategies that specifically impact FQHCs in their efforts to increase adult immunizations rates among their medically underserved patients.
Resources for vaccination of adults in FQHCs from the National Association of Community Health Centers (NACHC) and National Adult and Influenza Immunization Summit (NAIIS):
