Pediatric Coding Alert

Question: The coder at another practice recently told me that 99211 is allowed with a well diagnosis when giving vaccines. But our understanding was that we can’t automatically bill 99211 with these visits. Can you advise?

Answer: You cannot bill 99211 with shots routinely—you can only bill the vaccine administration codes in most cases.

Exception: You can bill a 99211 with a “shots only” visit if you document a different diagnosis other than the vaccines, and the nurse does an assessment. For example, a child presents for vaccines but the parent asks the nurse to double check the child’s weight and blood pressure since they were elevated at the last well child check. The nurse does this, documents the vitals, and reviews them with the mother, comparing them to the prior visit’s data. In this case, you’d report 99211 with 783.1 (abnormal weight gain) and the code for elevated blood pressure (such as V71.7), then bill vaccines with their appropriate code and admin fee.

You’ll append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99211. Separate E/M documentation is a must. Keep in mind that billing a 99211-25 with any immunizations will make the visit subject to a copay and deductible. If there is not a medically necessary E/M visit, the immunization only visit would include the appropriate immunization administration codes (90471-90474) and vaccine products (90476-90749).