Internal Medicine Coding Alert

Question: An 18-year-old female established patient, fearing she has H1N1, reports to the internist complaining of weakness and fatigue; she rates her fatigue at 8 on a scale of 10, saying "I can barely get out of bed." After a level-three E/M that includes a rapid screen, the physician determines the patient does not have H1N1, but is suffering from secondary anemia due to heavy, excessive bleeding associated with uterine fibroids. The patient requests an H1N1 vaccination, which the nurse provides. How should I code this encounter?

Oregon Subscriber

Answer: You'll report an E/M for the internist's services and a code for the vaccination admin. On the claim, report the following:

99213 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ..., for the E/M service;

90470 -- H1N1 immunization administration[intramuscular, intranasal], including counseling when performed, for the vaccine administration;

modifier 25 -- Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service, appended to 99213 to show that the E/M and vaccination were separate services;

V04.81 -- Need for prophylactic vaccination and inoculation against certain viral diseases; influenza, appended to 90470 to show the medical reason for the H1N1 vaccine;

280.0 -- Iron deficiency anemia secondary to blood loss (chronic), appended to 99213 to represent the patient's uterine bleeding;

626.6 -- Metrorrhagia, appended to 99213 to represent the patient's uterine bleeding;

218.9 -- Leiomyoma of uterus, unspecified, appended to 99213 to represent the patient's uterine bleeding;

Note: You have a CPT code for the H1N1 vaccine: 90663 (Influenza virus vaccine, pandemic formulation). Because the vaccine is currently free for physicians, you do not need to report this code on your claim form.