Medicare Compliance & Reimbursement

Warning: Brief history and review probably won't qualify for E/M code when your NP administers a vaccine.

Question: A nurse practitioner (NP) sees a 65-year-old established patient for a pneumonia vaccination. Before administering the vaccine, she records a brief history of the patient, checks the patient's vital signs, and rules out any contraindications for the vaccine. Should we consider the E/M part of the service or is it OK to report an E/M in addition to the vaccination codes?

Answer: You probably shouldn't report a separate E/M. From your description of the NP's actions, she did not do much beyond providing the E/M service built into most CPT codes. For that reason, you should just report the vaccination codes.

On the claim, you should report the following:
 • 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use) for the pneumonia vaccine
 • 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/ toxoid]) for the pneumonia vaccine administration.
 Note: For Medicare patients, and payers that observe Medicare rules, use G0009 (Administration of pneumococcal vaccine when no physician fee schedule service on the same day) for the administration rather than 90471.

You should also be sure to link V03.82 (Need for prophylactic vaccination and inoculation against bacterial diseases; Streptococcus pneumoniae [pneumococcus]) to 90732 and 90471 (or G0009) to prove medical necessity for the service.

Explanation: All CPT codes have an inherent E/M service (a brief patient assessment required before undergoing any type of procedural service) built into them. The E/M the NP provides the patient during the vaccination must go beyond this inherent E/M in order to report a separate E/M code.

If you can identify a problem that the nurse assesses and separately treats (at the direction of the physician), you might be able to report an E/M service along with the immunization codes.