Internal Medicine Coding Alert

Immunizations and vaccinations, particularly influenza and diphtheria/tetanus, are frequent procedures in internal medicine offices. But many internal medicine practices report problems getting paid for all of the services involved in a normal office visit, plus a vaccine administration.

Some practices get paid for the office visit and the actual vaccine serum, but not the administration (90471 or 90472). Others have more complicated problems, such as insurance carriers bundling the vaccine payment into the office visit or, worse, bundling a separate evaluation and management (E/M) service into payment for the vaccine.

Rules for coding vaccine administration are more complicated than they seem at first glance, says LuAnn Langel, coding manager for Medical Associates, PC, a multispecialty physician practice in LeMars, Iowa.

It is different if the patient is a Medicare patient, she says. When a Medicare patient has any kind of injection, other than for pneumonia or the flu, they will not pay for an administration fee in addition to a separate E/M code. They will for pneumonia and flu vaccines.

According to CPT guidelines for immunization administration for vaccines/toxoids, If a significant, separately identifiable evaluation and management (E/M) service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes. Some carriers might require a -25 modifier with the E/M code.

One example would be when an adult patient comes to the office seeking treatment for a cold and, during the visit, also receives the hepatitis A vaccine. According to CPT, the office should report an office/outpatient E/M code (99211-99215), vaccine administration code 90471 (immunization administration, one vaccine) and code 90632 (hepatitis A vaccine, adult dosage, for intramuscular use) for the vaccine.

But Langel says that Medicare policy considers the administration service bundled into any other E/M service performed on the same day. They will only pay the administration codes if the vaccine injection is the only service performed by that physician for that patient on that day.

Private Insurance Plans

Some private insurance plans also do not cover the administration fee, says Langel, and they never pay for it, even though reimbursement for the serum codes was reduced when the administration codes were added to CPT two years ago. Some insurance plans wont pay the administration fee even if there is no separate E/M on that day, she says. The patient may come in for routine immunizations, diphtheria, polio, Hib (Hemophilus influenza b), etc. There are certain plans that will pay just for the serums.

There is nothing coders can do about this situation, except to check the practices contracts with each plan to know whether they pay for the administration, she says. The practice administrators and managers will have to resolve the conflict during contract negotiations if this has a significant impact on the office.

Bundling Office Visits Into Administration

One reader recently reported that a private insurer was bundling the office E/M code into the vaccine administration code and only paying an administration fee (about $8) for an entire office visit that includes evaluation and management services. This is definitely not appropriate and is either the result of a misunderstanding on the part of the carrier or a mistake in coding, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. If this happens, you should make sure that you have a different diagnosis code for the office visit and the vaccine administration, she says. This tells the payer that the office visit and the vaccine were for separate reasons.

For example, if a patient comes in for an annual preventive medicine exam and also receives an influenza vaccine, the ICD-9 code for the office-visit portion should be V70.0 (routine general medical examination at a health care facility, health checkup) and the code for the vaccine administration should be V04.8 (need for prophylactic vaccination and inoculation against certain viral diseases, influenza).

If the office visit on the same day of the vaccine administration is a preventive medicine exam, the practice must make sure the payer covers preventive visits, adds Callaway-Stradley. Many payers do not; this may be why they are only paying for the administration. If that is the case, then the practice needs to seek payment for the overall office visit from the patient.

If none of these issues are the problem, the practice may need to have a conversation with the plans medical director, advises Kay Faught, CPC, of CPT Coding and Clinic Management, a consulting firm in Livermore, Calif.

Sometimes the person processing the claim and the practices payer representative just do not understand what services the codes represent, she says. If this is a common occurrence, you may need to talk to someone in a higher position of authority at the plan to get the situation straightened out. There is no way it is appropriate to just get an administration fee as reimbursement for an entire office visit.