Resolved Supervising signature for immunizations

[CharitoC_65239]

Hello all,

Since Medical assistants are able to give immunizations, does the notes still need a supervising provider signature or is the Medical assistant able to sign and approve the notes themselves? Is a signed order from the provider good enough? What if there is no order from the provider because the patient just wanted an update on their immunizations? What are the guidelines for signatures for Medicare/ Medicaid compared to a commercial insurance? Where can I find billing guidelines on this? Please help!

TYIA!

 

[Lori]

Documentation details​

Federal requirements mandate that you document five things when you administer a vaccine:

1. The name of the vaccine and the manufacturer;
2. The lot number and expiration date of the vaccine;
3. The date of administration;
4. The name, address, title, and signature (electronic is acceptable) of the person administering the vaccine
5. The edition date of the Vaccine Information Statement (VIS) and the date the patient or parent receives the VIS.

The VIS is a CDC-approved description of the vaccine, its benefits, and adverse effects, and it includes information about the disease the vaccine protects against. This is written at a level most patients can understand.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/signature_requirements_fact_sheet_icn905364.pdf

• Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:
• (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
• (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.

Resource - Z Codes

The Importance of Z Codes Z codes, found in Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) of the ICD-10-CM code book, may be used in any healthcare setting. The ICD-10-CM Guidelines for Coding and Reporting instruct us to code for all coexisting...

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Resource - Vaccine/Immunization

How does CPT define a vaccine component? A component refers to all antigens in a vaccine that prevents disease(s) caused by one organism. Multivalent antigens or multiple serotypes of antigens against a single organism are considered a single component of vaccines. Combination vaccines are those...

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