Pediatric Coding Alert

There are times when an immunization is the only procedure a child needs. The best way to recoup your costs is to code for an office visit and an immunization, as covered in the January issue of PCA (pages 1-3). You should use CPT 99211 for an established patient (its not likely that you will give a new patient an immunization without a complete examination), and that will cover the costs of having a nurse give the shot. The example we used was DTaP, which would be 90700 and 99211.

Michael A. Fabrizio, MD, PC, of Pittsfield, MA, thinks this is a good idea, but wonders what diagnosis code to use. We would appreciate your input as this is something our office does frequently and we are not being reimbursed.

We know that some practices use the diagnosis code V20.2 when giving just an immunization. This is for a routine infant or child health check, and does include immunizations appropriate for age. However, this code is likely to cause you problems getting adequately reimbursed with many managed care plans, explains Angela Snyder, billing coordinator for Watson Salsbury Pediatrics, a part of the 28-pediatrician Capitol Area Pediatrics based in Fairfax, VA.

If the child comes in for a well visit at another time, then youre going to have two diagnosis codes for that checkup at different times, Snyder explains. Since insurance wont cover more than one well visit for a designated time period, it will automatically raise a red flag if you use the V20.2 diagnosis code twice within that period.

Snyder uses the prophylactic vaccination codes (see below) if the child didnt come in for a complete physical. For example, if a child comes in for a varicella shot, she would use 99211 for the first-level office visit, 90716 for the immunization, and the diagnosis code V05.4 for both CPT codes.

Its frustrating because every insurance is different, Snyder says. You have to do what each insurance company says [and reimburses for].

There are two basic ways that a child will get immunizations outside of a well visit. One is if the shots are deferred because the child has, say, an ear infection at the time of the well visit. When the child does come back for the shots, Snyder uses the appropriate procedure codes and diagnosis codes for the immunizations, and also uses a 99211. But for the date of illness, I put the date they were seen for the physical, says Snyder. Making it the same date helps prevent confusion on the part of many insurance companies, says Snyder.

Thats because even using the prophylactic vaccination diagnosis codes when immunizations are given as the only service, some insurance companies think that a well visit is being done, says Snyder. This happened just recently, when a child came in for a varicella shot, she says. We coded a 99211, and they processed it as a well visit, Snyder reports. Then, when the child came in a month later for his well-visit, the insurance company denied it, saying he had just had one. Snyder appealed the denial, of course. In the first go-round with the insurance company, the representative said Snyder shouldnt have coded a 99211. But I said, `The nurse administered the immunization, says Snyder. It may sound obvious. But it is true. And furthermore, it works.

(Tip: Snyder cautions that you should not use 99211 for the administration of an immunization unless the nurse does more than just give the shot. That means she has to give all the information about the immunization to the parent, including information about side effects and expiration. And she has to document that she gave this information. Then, when you appeal, you have that proof in the chart.)

What does Snyder do when she has coded a 99211 and the insurance company wont pay it? If the insurance company says its the patients responsibility, we bill the patient, Snyder reports. If they say its a write-off, we appeal. Isnt this a lot of work -- appealing all the write-offs? Yes, admits Snyder. But its worth it. You only need to win one time with an insurance company, she says.

Sometimes the insurance company says they will pay $10 on an office visit of 99211, and the rest is the patients responsibility, says Snyder. Then, we bill the patient for the rest.

Parents havent complained about paying for the administration of the vaccines, says Snyder. And, as Fabrizio, the reader who brought up this issue, recognizes, if you dont bill for it -- which means putting the 99211 code in -- you wont get reimbursed.

Remember, if the insurance company doesnt want to pay for the 99211 as well as the immunization procedure code, you might want to refer them to CPT 98. In the introduction to the immunization section, it states: Immunizations are usually given in conjunction with a medical service. When an immunization is the only service performed, a minimal service may be listed in addition to the injection.

Diagnosis codes for immunizations

These are the most commonly used diagnosis codes for immunizations given in pediatric practices:

Need for prophylactic vaccination and inoculation against bacterial diseases
-- V03.5 Diphtheria alone
-- V03.6 Pertussis alone
-- V03.7 Tetanus toxoid alone
-- V03.8 Other specified vaccinations against single bacterial diseases
-- V03.81 Hemophilus influenza, type B (Hib)
-- V03.89 Other specified vaccinations
-- V03.9 Unspecified single bacterial disease

Need for prophylactic vaccination and inoculation against certain viral diseases
-- V04.0 Poliomyelitis
-- V04.1 Smallpox
-- V04.2 Measles alone
-- V04.3 Rubella alone
-- V04.6 Mumps alone
-- V04.8 Influenza

Need for other prophylactic vaccination and inoculation against single diseases
-- V05.3 Viral hepatitis
-- V05.4 Varicella

Need for prophylactic vaccination and inoculation against combinations of diseases
(Note: Use additional single vaccination codes from categories V03-V05 to identify any vaccinations not included in a combination code.)
-- V06.1 Diphtheria-tetanus-pertussis, combined (DTP)
-- V06.3 Diphtheria-tetanus-pertussis with poliomyelitis
-- V06.4 Measles-mumps-rubella (MMR)
-- V06.5 Tetanus-diphtheria (Td)
-- V06.8 Other combinations
-- V06.9 Unspecified combined vaccine