Internal Medicine Coding Alert

Question: During an office visit, our nurse administered a B12 injection and a flu shot to an established patient. Can we code for both injections in addition to the office visit?

Answer: The answer depends on the circumstances. First, report the appropriate code for the flu vaccine (e.g., 90658, "Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) depending on the type of vaccine administered as well as the appropriate code for the administration of the vaccine, such as 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]). If the administration involved physician counseling with a patient 18 years of age or younger, you will use code 90460 for the administration; for a Medicare patient, the administration code is G0008 (Administration of influenza virus vaccine).

For the B12 injection, report the administration with CPT 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). Include J3420 (Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg) for the vitamin B-12 itself.

Finally, if the office visit was significant and separately identifiable from the two injections, you may add the appropriate office visit code from 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). In this case, be sure to 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 the office visit code.

Exception: If the patient receives the B12 shot as part of a scheduled administration plan which otherwise involves no evaluation and management of the patient, report the flu shot and the B-12 injection, but not the office visit.