EM Coding Alert

Question: A patient came in for a flu shot. Can I report an office visit code (such as 99212) or should I just report 90658 and 90471?

Pennsylvania Subscriber

Answer: No. Based upon the given information, simply administering an injection, such as a flu shot, does not warrant reporting an evaluation and management (E/M) code like 99212 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; and straightforward medical decision making …)

In your case, you would only report the codes for the vaccine administration like 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) and the appropriate vaccine product code such as 90658 (Influenza virus vaccine, trivalent [IIV3], split virus, 0.5 mL dosage, for intramuscular use).

The only reason you should report 99212 is if the physician also provided a significant, separately identifiable E/M service in addition to administering the flu shot.

Importance of medical necessity: Remember, medical necessity must always support an E/M service, or any service the physician provides, so the medical record must show sufficient information supporting the reason for the visit.

Report 99212: If the physician did provide a significant, separately identifiable E/M service in addition to administering the flu shot and the medical documentation supports medical necessity for the service, you can report 99212.

According to CPT^® 2017, a 99212 requires the physician to spend at least 10 minutes of face-to-face time with the patient and/or family and to perform at least two of the three components — history, physical exam, and medical decision making. You should report 99212 for established patients only.

Don’t forget modifier 25: You would also append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99212.