Pediatric Coding Alert

Although your nurses' time is packed with patients coming in for flu shots and added immunization visits, you've got to be resilient in reporting only allowed 99211s or you could face thousands in paybacks.

That's the lesson one office learned. Two different insurance companies chart-audited the practice, which got hit with having to pay back thousands of dollars, not including lawyer fees and staff overtime.

Protect your practice from being the next 99211 (Office or other outpatient visit ... Typically, 5 minutes are spent performing or supervising these services) payback statistic. Before marking the code on a claim involving immunization administration (90471-90474), make sure you can answer "Yes" to these questions.

You should not routinely use 99211 when administering a flu shot or any other vaccine-only appointment, says Christina Scalice, billing manager at Park Pediatrics LLP in Floral Park, N.Y. "Verifying that a patient is 'OK' by taking routine vital signs to administer the vaccine and then making sure the patient is 'OK' before leaving the office are components of the administration code (90465-90474)."

Include taking vitals and a brief history, as well as counseling on the immunizations/flu shots, in the administration code. Look for documentation showing the nurse did something significant besides give the vaccine to support coding the visit. When a patient is scheduled for a flu shot (or any other vaccine), Scalice says 99211 is appropriate only if the:

(a) patient has additional medical needs, such as blood pressure checked for medication monitoring (b) nurse evaluates, manages, and documents the significant and separate complaint(s) or problem(s).

Check out this example of when 99211 + 90471-90474 is OK from Nancy Bishof, MD, a private-practice pediatrician in Lexington, Ky. "A mom brings in a child and says, 'He had a cold last week. Are you sure he can get the vaccines?' The RN assesses the child (listens to his chest, peeks in his throat, etc.) and documents the assessment." Since the nurse provides a medically necessary, significant, separately identifiable E/M service in addition to the vaccines, you can bill 99211 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), Bishof says. Also, report the vaccine/toxoid product codes (90476-90749) and the corresponding administration codes (90471-90474). Does a Separate Diagnosis Exist?

Linking a problem-oriented diagnosis to 99211-25 tells you and the insurer that the nurse had to assess the patient's condition. A separate diagnosis also helps support that the service is significant and separate from the minor E/M included in the vaccine administration code's value. CPT, however, does not require different diagnoses to report an E/M-25 service and a procedure.

Pitfall: Insurers may apply this restriction to 99211-25 and 90471-90474. "You'll need to use a separate diagnosis code  for instance, for URI (465.9), stomachache (536.8), rash (782.1)," or cough (786.2), Bishof reports.

Even if you answer "Yes" to the above questions, do not report 99211 with 90471-90474 to insurers that follow Medicare's Correct Coding Initiative (CCI). "According to CCI edits, you cannot charge a 99211 with 90471, not even with a modifier," reports Kathleen Goodwin, CPC, LPRN coding coordinator at LaPorte Regional Physicians Network in Indiana.

Private payers that adopt Medicare's edits disallow reporting the code pair. "Some insurers (Humana, for example) won't pay the 99211," Bishof reports. Beware that some experts give advice assuming that you're billing Medicare. "The American Academy of Professional Coders said we cannot bill the 99211 with immunizations and flu shots," reports Tina Steece, billing manager for the 20-physician Pediatric Associates Inc.,which has four offices in Ohio.

For non-CCI payers, follow CPT's directive: "If a significant separately identifiable Evaluation and Management service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes," state the Immunization Administration for Vaccines/Toxoids guidelines.

Do not extend the edit to the other established patient office visit codes (99212-99215). "Code 99211 is the only office visit that you can't attach a 25 modifier" with a nurse-only administration visit, Goodwin says.

"Trying to come up with the documentation to support a 99211 got a little muddy," says Goodwin. Make sure that if you're using 99211 with 90471-90474, you have documentation to back up the nurse visits.

You'll protect your 99211 billing and keep your office compliant if you teach nurses what documentation these encounters require. Encounter documentation should be a separate entry from the vaccine charting, according to the American Academy of Pediatricians. The academy recommends including these items:

" Date of service and reason for visit

" Brief history of any significant problem(s) evaluated or managed

" Any exam elements (such as vital signs or appearance of a rash)

" A brief assessment or plan along with any counseling or patient education done

" Signatures of the nurse and supervising physician.