Pediatric Coding Alert

AAP Reveals When You Should Bill a Nurse Visit With Vaccine Administration

Published on Wed Feb 16, 2005

Report E/M for encounter that goes beyond these staff services

This just in: You should reserve 99211-25 with 90471-90474 for a medically necessary exam and service.

The American Academy of Pediatrics (AAP) breaks new ground by publishing a position paper with guidelines for when you should bill a nurse visit with an immunization visit. Here's what the experts say regarding CPT 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician; usually, the presenting problem[s] are minimal; typically, 5 minutes are spent performing or supervising these services).

E/M Must Be Medically Necessary, Separate

First, get out of the habit of routinely assigning 99211 for nurse-only vaccine administration encounters. You should instead give "careful consideration ... regarding the significance and medical necessity for such a visit," states the AAP Committee on Coding and Nomenclature (COCN) in its paper "When Is It Appropriate to Report 99211 During Immunization Administration."

This paper delves into uncharted territory. CPT guidelines' 99211 description "did not address the issue of immunization," says Maria M. Torres, CPC, CMM, CCC, CMSCS, a primary-care consultant with Bermudez Medical Consulting Services in Tampa, Fla.

Old way: Coders thought they could bill 99211 when the nurse documented the vital signs and the topic she discussed with the patient and/or parent, Torres says. "Coders also felt that by adding modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)" they met the necessary requirements.

New way: To determine whether you should assign 99211-25 on 2005 claims for a nurse-only vaccine administration visit, ask two questions:

1. Does the nurse perform a medically necessary service in addition to the immunization administration?

2. Is that service significant and separate from the vaccine administration?

Bottom line: If you can answer "yes" to both questions, you should report 99211-25 in addition to the immunization administration (90471-90474) and the vaccine product(s).

Watch out: Don't assign 99211-25 and 90465-90468 (Immunization administration under 8 years of age ... when the physician counsels the patient/family ...). Because the pediatric-specific vaccine administration codes (90465-90468) require physician counseling, a nurse may only use the existing vaccine administration codes 90471-90474.

90471-90474 Contain These Services

You should report 99211-25 when the nurse performs more extensive services than she would during a brief vaccine administration encounter.

The AAP paper states that the nurse must perform more than:

administrative staff services, such as making the appointment, preparing the patient chart, billing for the service, and filing the chart

clinical staff services, such as greeting the patient, taking routine vital signs, obtaining a vaccine history on past reactions and contraindications, presenting a Vaccine Information Sheet (VIS) and answering routine vaccine questions, preparing and administering the vaccine with chart documentation, and observing for any immediate reaction.

Surprise: The resource-based relative value scale (RBRVS) values for 90471-90474 now include many of the services that you previously reported separately with 99211, according to the AAP. The increased RBRVS reimbursement rates for injection vaccine administration (90465-90466, 90471-90472) take into account the added services.

Action: You should review your current immunization charges to make sure insurers increase them to correspond with the new RBRVS published values. Download the 2005 payment rates for 90465-90474 from the site www.aap.org/visit/2005rbrvs.pdf.

Stand-Alone E/M Clinches Nurse Visit

Another way to test 99211's stand-alone capacity is to see if separate chart notes can support both the service and the vaccine administration.

First, encourage your nurses to use separate documentation for each service. Staff should write the encounter as one entry. They should then separately chart the vaccine, usually using the immunization history sheet.

You can also use templates to obtain duel documentation. You can use one template for the encounter and one for the vaccine information, says Victoria S. Jackson, CEO of Southern Orange County Pediatric Association in California. "To separately bill the visit, the E/M template must be able to stand on its own and contain a significant chief complaint or problem that the nurse evaluates."

Get started: You will have to implement a training process to ensure that the nurses know the examination, encounter and documentation necessary to report 99211-25 in addition to 90471-90474, Torres says. Make sure you establish clear protocols to define these requirements.

99211-25 Payment Is Uncertain

The verdict is still out on whether the AAP's guidelines mean an end to denials for nurse visits with vaccine administration.

"Payers that follow Medicare policy may have edits on reporting 99211-25 and 90471-90474 together when the nurse only gives a vaccine and delivers no other service," says Joel Bradley Jr., MD, a pediatrician at Premier Medical Group in Clarksville, Tenn. Other insurers may allow billing the two together as they previously have.