Pediatric Coding Alert

Consider this common situation in pediatrics: Because one or more immunizations couldnt be given during a recent well-visit, the nurse administers them at a follow-up visit. But should the subsequent service be coded as a so-called nurse visit, 99211, or as a vaccine administration visit, 90471-90472?

The 99211 is tempting because it does not require the presence of the pediatrician, but it has its own challenges.

This is the little code with the big headache, says Carolyn Roberts, CCS, CCS-P, CPC, coding and reimbursement analyst for Bay State Medical Education and Research Foundation in Springfield, MA. She prefers using vaccine administration codes instead.

Theres a code for administration of vaccines,
and you should use that, says Roberts (the codes
are 90471 for immunization, and 90472 for each subsequent immunization). You cant charge 99211
and administration.

Alison Smith, CCS, coding manager for Sentinel Health Partners, a billing firm based in Fayatteville, GA, agrees. We leave it up to our office managers as to whether they want to use the administration fee or 99211, she says. But we recommend the administration fee, and if the insurance company doesnt pay it, we appeal.

The problem with using 99211 too often, says Smith, is it could skew your bell curve for E/M codes. You need to be careful using 99211, because if you use it too often, the insurance companies are going to ask you why youre doing so many low-level office visits, she says.

But its true that there are insurance companies that are not up to speed with the administration codeseven though they were created for CPT 1999. So she recommends that any practice that decides to use 99211 instead of the vaccine administration codes have a statement, in writing, stating that this is the policy.

Say that it is the practice policy to use 99211 when a nurse is administering a vaccine, instead of 90471 or 90742, says Smith. This way, you can show the insurance companies that you are not overusing 99211.

However, Smith reiterates that practices would be better off using the vaccine administration codes. The only way this will get turned around and have all insurance companies pay for it is if all pediatric office managers bill for it, she says.

The Rules

Another issue is that 99211, while it does not have the requirements that other E/M services codes have (no history, examination, or medical decision-making are necessary), does have some rules.

You need medical necessity, explains Roberts. And you should include the following documentation: the patients vital signs, the reason why the patient is there, a diagnosis, the date of service, the service provided, the signature of the nurse and the fact that the physician is present in the suite.

The pediatrician must co-sign the note at the end of the day, when the nurse charges 99211. Also, if you are using 99211 only because the insurance plan does not recognize the administration codes, you should add this to your written policy statement.

Finally, remember that 99211 is not literally a nurse visit. A pediatrician can use it too, for a minimal problem. But this probably wouldnt happen very often. Even weight checks, which are usually done by nurses, easily turn into 99212s when the parent starts asking questions and the nurse brings the pediatrician in.