Internal Medicine Coding Alert

Question: Can we bill an office visit in addition to the administration of vaccine? Or can we bill an office visit instead of the administration?

Illinois Subscriber

Answer: Part of the coding confusion seems to come from the latest release of Medicares Correct Coding Initiative (CCI), which bundles all evaluation and management (E/M) codes with the administration of vaccine codes (G0008 for influenza and G0009 for pneumonia). This CCI edit, however, is really only a restatement of Medicares current national policy.

That policy (in section 4480.1 of the Medicare Carriers Manual) permits a carrier to provide additional reimbursement if the office visit was incurred for reasonable and necessary services in addition to the vaccination.

Many local carriers follow that policy and will reimburse for a significant, separately identifiable E/M service. An example of a significant, separately identifiable service would be when a Medicare patient comes in to talk about his or her hypertension and the internist takes an appropriate patient history, performs a physical examination and does medical decision-making regarding the hypertension. At the end of the visit, the patient requests and is given a flu shot from the internist. In this case, the internist could bill an E/M visit with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached, G0008 for the administration of the vaccine, and the appropriate CPT code for the vaccine itself.

Some local carriers do not permit billing an E/M service under any circumstances. National Heritage Insurance Company, the Medicare Part B carrier for California, for example, published a notice in its June 2000 Medicare bulletin that it was inappropriate to bill G0008 and G0009 in addition to a same-day physician fee schedule service, such as an office visit.

If the patient comes in only to receive a flu shot, most carriers instruct the internist to report only the vaccination administration code and the code for the vaccine itself.

For non-Medicare patients, 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid]) should be reported along with the code for the vaccine if the patient comes in only to receive a flu shot. If the private payer closely follows CPT coding guidelines, it probably will reimburse for a significant, separate E/M service because the introductory note to the immunization section of CPT states that if a significant, separately identifiable evaluation and management 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.

Because payment policies of Medicare carriers and private payers vary on this issue, internists should contact these carriers and payers to get specific instructions and requirements for billing influenza and pneumonia vaccinations.

Additional information for Reader Questions was provided by Jim Stephenson, president of North Central Medical Management, a multispecialty medical management company in Elyria, Ohio.