Pediatric Coding Alert

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 [...]