Pediatric Coding Alert

While it is technically correct coding to bill 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) and the immunization administration codes (90471 for one vaccine, 90472 for each additional vaccine) during the same visit at which no doctor is seen, in practice you should bill both the visit code and a vaccine code only when the nurse does a significant amount of extra work. The administration codes cover all of the work involved in giving the immunization, and if managed care in addition sees a high number of CPT 99211 s billed for the same encounter, they may want to conduct an audit.

Ever since the American Medical Association (AMA) created the immunization administration codes last year, there has been confusion about how to bill those visits when a child comes in for immunizations only. These visits usually take place a week or two after a well visit when the pediatrician determined that due to an ear infection, or some other problem, immunizations should not be given. The child returns once he or she is well again and gets the immunization shots. Billing immunizations for the well visit is simple enough: bill the age-appropriate preventive-medicine-services code, plus the immunization administration codes (90471-90472). But when a child comes in for shots alone, many pediatricians wonder if they can bill 99211 (also known as the nurse visit code) in addition to the administration codes, or if they should bill just the 90471/90472.

CPT makes it clear that you can report preventive-medicine services as well as evaluation and management (E/M) services (including 99211) at the same visit as 90471/90472. In the November 1999 issue of CPT Assistant, it is clearly stated that 99211 may be reported in addition to 90471/90472 and the vaccine product code (90476-90749): When a nurse under the physicians supervision reviews the patients chart, takes the childs blood pressure and temperature, provides vaccine information, instructions and consent forms to the parent and prepares the vaccine product prior to the administration of the vaccine.

The AMA put this in CPT Assistant partly because the American Academy of Pediatrics (AAP) requested clarification. And the item does indicate that its okay to use 99211 in addition to 90472/90472 for immunization-only visits, says A.D. Jacobson, MD, FAAP, former member of the AAPs coding and reimbursement committee and a pediatrician at Pediatric Associates, a four-pediatrician, one-nurse practitioner practice in Phoenix, Ariz. But, as a general rule, Jacobson advises against it. Yes, you can use both, he says. But this is an example of the art of coding.

At Jacobsons practice the combination of 99211 and 90471/90472 is not used often. For most of the patients who are coming in for immunizations, I dont think the work justifies the extra code, he says. Jacobson warns that using 99211 every time a child comes in for shots could cause problems with managed care. If I were a managed care company and I noticed a really high number of 99211 codes, I would investigate, he says.

The pediatrician with too many outside codes (99211 and 99215) is damaging the bell-shaped curve, in which the majority of visits should be 99213, and risking potential audits says Jacobson. The bell-shaped curve means that the majority of your codes are third level, the fewest are first and fifth level, and second and fourth level codes are in the middle but equal. If you have too many second level codes and not enough fourth level codes, the curve will be skewed to the left, and you will not be getting reimbursed properly. Practices can be punished for using too many low-level codes as much as they are for too many high-level codes.

Note: For more on the bell-shaped curve, see Improve Reimbursement for Office Visits with Bell Curve, page 11 in the February 2000 issue.

Teri Risley, a health policy assistant at the AAP, agrees with Jacobson. Unless there is something significant enough that requires the nurse to use the 99211, you shouldnt use it, she says. For example, if a child was sick, and a nurse did a follow-up of the illness to see if the immunizations could be given, that might justify a 99211. But, Risley notes, its likely that in such a case, a pediatrician would see the child, making the visit at least a 99212.

Jacobson also brings up the problem of the co-pay that usually goes along with code 99211. Remember, most of these parents have co-pays, he says. If you charge 99211, they may have a twenty or twenty-five dollar co-pay. The big concern, says Jacobson, is that these parents may not come back in a timely way to get their children immunized if they know theyll have a big co-pay. There is no co-pay for 90471/90472.

But there are times when Jacobson does bill both codes. If, for example, the nurse has a five or ten minute discussion about the value of vaccines, then we would bill a 99211, he says. Some parents are concerned about the number of vaccines their children are receiving, and the nurse may need to spend time discussing the benefits and risks of the vaccines. In this case, billing 99211 with 90471/90472 is justified because the extra work involves more than just the administration of the vaccines. But, in my opinion, if the nurse just gives the third polio vaccine, and thats it, its not ethical to use 99211, he says.

Note: For more on immunization codes, see Understanding the New Vaccine Administration Codes, page 36 in the May 2000 issue.