Oncology & Hematology Coding Alert

Question: We have been receiving denials for flu vaccine codes when submitted with E/M visits and other in-office procedures. We have been using modifier 25 with these E/M codes and have also reported the flu vaccine code. What can be the rationale for these denials? Is our reporting not appropriate?

Tennessee Subscriber 

Answer: You need to again check the codes that you are submitting. The Correct Coding Initiative (CCI) bundles E/M office or inpatient codes into the following vaccine administration codes: 

• 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered), 
• 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]), and 
• 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]). 

Which E/M codes are bundled? Note that CCI does not bundle E/M codes other than 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) into the Medicare influenza vaccine administration code, G0008 (Administration of influenza virus vaccine).

Check the modifier indicator: The modifier indicator to this code bundling is ‘1’ which indicates that you can unbundle the codes using an appropriate modifier. You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M visit code. The exception to this rule is code 99211. The modifier indicator for the edits that bundle this code with all of the vaccine administration codes above is “0.” That means CCI edits never allow you to report 99211 for the same patient on the same date as a vaccine administration. 

Note: You should not report an E/M visit code if your physician only records a brief history, checks the patient’s vitals, and rules out any contraindications to the administration of the vaccine. Such a minimal assessment is likely to be considered part of the vaccine administration itself.  In such a case, you will only report the administration code and not an E/M code. You can report an E/M service with a vaccine administration code if and only if the E/M service was significant and separately identifiable from the vaccine administration as reflected in the physician’s documentation of the encounter.

As noted, you need to have proper documentation to justify the medical necessity and to support your physician actually provided a distinctly separate E/M service while also giving the patient a flu shot. In such a case, a different diagnosis will be present to support separate payment of the office visit code. In either case, you should map the ICD-9-CM code V04.81 (Need for prophylactic vaccination and inoculation against other viral diseases; influenza) to the code for the influenza administration. You also map it to the CPT® code for the influenza vaccine itself if it represents an expense to the physician office. If you are using ICD-10-CM codes, you will have to use Z23 (Encounter for immunization) instead of V04.81.