EM Coding Alert

Question: When patients come in for a flu shot, our nurse sees the patient first. She documents a brief history, looking for any contraindications and counsels the patient on the vaccine. Can we report a 99211 along with the administration code for these encounters?

North Dakota  Subscriber 

Answer: No, you cannot report a separate E/M code for this encounter, even 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional). You should not report an E/M visit code if your nurse (or physician) only counsels on the vaccine. Your payer will consider this the minimal assessment part of the vaccine administration itself.

Here’s why: According to Correct Coding Initiative (CCI) edits, E/M services are bundled into the vaccine administration codes 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered), 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]), and 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]).

The modifier indicator for most of these bundles is “1,” which indicates that you can separate the codes using an appropriate modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). However, the exception to this rule is code 99211. The modifier indicator for the edits that bundle this code with the vaccine administration codes above is “0.” That means CCI edits won’t allow you to report 99211 for the same patient on the same date as a vaccine administration.

Therefore, you will only report the administration code and not an E/M code. You can report an E/M service with a vaccine administration code if and only if the E/M service was significant and separately identifiable from the vaccine administration as reflected in the physician’s documentation of the encounter.

Diagnosis: Link ICD-9 code V04.81 (Need for prophylactic vaccination and inoculation against other viral diseases; influenza) to the code for the influenza administration as well as the CPT^® code for the influenza vaccine itself, which you should also report. If you are using ICD-10 codes, you will have to use Z23 (Encounter for immunization) instead of V04.81.