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 [...]