Pediatric Coding Alert

Diagnosis is key to 99213 payment

Are payers denying rechecks with rescheduled immunizations? Experts show you how flawless CPT and ICD-9 coding can boost E/M service reimbursement.

1. Check Your Encounter Coding

Before you appeal office visit denials, make sure that you correctly report the E/M service, administration and vaccinations.

Real-world example: A mother returns today with her 6-month-old daughter for an otitis media recheck. At the previous visit for a scheduled well check, the pediatrician found that the infant had an ear infection. Although the pediatrician still performed the preventive medicine service, he deferred giving the infant her prescribed immunizations. At the follow-up visit, the pediatrician determines that the infant's infection has resolved and that she is well enough to receive her immunizations.

In this scenario, you should report the office visit code (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...),  long with the following immunization codes, says Bobbi Katz, billing specialist at the seven-pediatrician Westfield Pediatrics in Westfield, N.J.:

90471 - Immunization administration (includes  percutaneous, intradermal, subcutaneous, intramuscular and jet injections); one vaccine (single or combination vaccine/toxoid)

90648 - Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4-dose schedule), for intramuscular use

+90472 - ... each additional vaccine (single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) diphtheria, tetanus toxoids, and acellular pertussis (DtaP) immunization administration

90700 - DtaP, for use in individuals younger than 7 years, for intramuscular use

+90472 - inactive polio virus (IPV) immunization administration

90713 - Poliovirus vaccine, inactivated (IPV), for subcutaneous use.

Insurers may reject the E/M service, which would cut about $52 (99213's payment, based on the National Physician Fee Schedule, which private payers may adapt). You may end up asking whether you're coding the encounter correctly.

Bottom line: Yes, you are. "If the immunizations are given as part of a broader E/M service, then it is appropriate to report the vaccine product, the vaccine administration code, and the appropriate E/M service code," states the American Academy of Pediatrics (AAP) in Coding for Pediatrics.

2. Examine Your Pediatric Diagnostic Links

Your next step? Make sure you're using the appropriate diagnoses.

Try this: Link your E/M service to the original sick diagnosis and indicate that the illness is resolved. In the above otitis media scenario, you should report the original otitis media diagnosis code (381-382) in the primary position.

"Otitis media is the reason the child is coming back for a follow-up," says Charles A. Scott, MD, FAAP, a pediatrician at Medford Pediatric & Adolescent Medicine in Medford, N.J.

To indicate that you have completed the condition's treatment, you should assign V67.59 (Follow-up examination; following other treatment; other) in the secondary position.

You should use the same vaccine ICD-9 codes that you would normally report at the preventive medicine service. Link V03.81 (Need for prophylactic vaccination and inoculation against bacterial diseases; Hib) to 90471 Hib administration), V03.81 to 90648 (Hib product), V06.1 to 90472 (DTaP administration), V06.1 to 90700 DTaP product), V04.0 to 90472 (IPV administration), and V04.0 to 90713 (IPV product).

3. Use Prophylactic Diagnosis With 99211

But you shouldn't use the "sick" diagnosis if a nurse checks the child for illness prior to administering the missed shots.

Suppose you cannot administer a 1-year-old boy's vaccinations during his annual visit due to a high fever. The mother returns with her son two weeks later. A nurse measures the baby's vital signs to determine that the fever has abated and that any current illness won't contradict vaccine administration. She then administers the missed Hib; measles, mumps and rubella (MMR); IPV; and varicella vaccines.

In this case, you shouldn't use the original condition's diagnosis (780.6, Fever). The nurse doesn't perform a full evaluation. Plus, most states don't permit nurses to diagnose illnesses.

Better way: You should use the prophylactic diagnosis. Attach all the vaccine-specific ICD-9 codes to the nurse visit and then attach the code that pertains to each shot.

If you apply this logic to the nurse visit with immunizations, you should report (see chart):