Pediatric Coding Alert

Question: In a pediatric office, is it correct to code CPT 99211 -25 with a vaccine CPT code? In this situation, a nurse sees the patient, takes his or her vital signs, and gives a vaccine. Most payers deny 99211 stating that the ICD-9 code for this visit cannot be a V code.
 
New York Subscriber

Answer: Coverage depends on how payers interpret a significant, separately identifiable E/M service. CPT states, If a significant, separately identifiable E/M 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.

Most pediatricians consider the pertinent elements that determine if a patient is healthy enough to have a vaccination sufficient to substantiate a significant, separately identifiable E/M service. For instance, prior to administering a DTP vaccine, a nurse reviews the childs history including any recent illness or previous reaction to vaccines. Taking the patients vitals and determining whether the patient is a candidate for vaccines at that time fulfills the exam and medical decision-making components respectively. Add to this the administrative costs (such as pulling/refiling the chart, printing receipts, etc.) and you have a pretty good argument for billing the E/M (99211-25, Office visit for the E/M of an established patient, that may not require the presence of a physician ; Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service for staff-provided exams and 99212-99215-25 for physician-performed services) in addition to the vaccine administration (90471-90474, Immunization administration ...) and vaccine product (90701, Diphtheria, tetanus toxoids, and whole cell pertussis vaccine [DTP], for intramuscular use).

Unfortunately, most carriers disagree and will usually pay for the additional E/M only if it was for a different diagnosis than the vaccine administration (such as V06.1, Need for prophylactic vaccination and inoculation against combinations of diseases; diphtheria-tetanus-pertussis, combined [DTP]). Some carriers pay for the E/M instead of the administration when both are billed. In those instances, the allowable for the E/M is lower than for the administration.

You could try to convince the carriers that your interpretation is correct by continuing to bill for the E/M and appealing denials with supporting documentation. Going after every payer takes time. An easier approach is to discuss the issue with the insurers when you renew your contracts. If you present them with a report of those E/M services denied over an extended time, such as six months, you might convince them to cover the service. Show them supporting documentation and stress the importance of the E/M services you have provided for free for the last six months. Failing that, inform your patients that 99211 may not be covered and have them sign a waiver before they see the nurse or doctor.