Pediatric Coding Alert

Test whether your separate-encounter coding is up-to-par

If you question whether an E/M service can stand alone from a vaccine administration, check your documentation against this expert-approved version. Look for Problem, Treatment Test your CPT 99211 (Office or other outpatient visit for the evaluation and management of an established patient ... ) during a vaccine administration encounter with the following American Academy of Pediatrics -approved vignette.

Hint: To determine whether you should bill a nurse visit, ask yourself whether the visit:

1. is medically necessary

2. is significant and separate from the immunization administration encounter.

Example: Your nurse sees a 7-month-old girl for influenza immunization. The nurse takes a brief history and learns the infant has a cough without change in appetite, sleep or activity level. He takes vital signs and assesses that the infant has no contraindications to getting the vaccine, and discusses the management of the respiratory problem with the mother. The nurse also documents that the patient meets the current guidelines for vaccination and has no contraindications to the immunization per the Centers for Disease Control and Prevention guidelines. Next, he reviews the Vaccine Information Sheet (VIS) with the mother and obtains immunization consent. The nurse then administers the influenza vaccine.

Answer: In this case, you should code the nurse visit in addition to the immunization administration. The nurse evaluates a significant problem - the infant's cough - and offers management options.

Because the nurse performs a medically necessary service that is significant and separate from administering the influenza vaccine, you should report 99211 appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in addition to 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intra-muscular injections; one vaccine [single or combination vaccine/toxoid]).

The claim should read:
  E/M service - 99211-25 linked to 786.2 (Cough)

  influenza vaccine - 90657 (Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use) linked to V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza)

  immunization administration - 90471 with V04.81. Write Separate E/M, Procedure Notes Documentation that supports billing 99211 for the above encounter could read:

The patient is here for the influenza vaccine. Mother reports a cough for several days without any fever. Patient is eating well and has not been experiencing wheezing or rapid breathing. Her temperature is 98.7F, and respiratory rate is 38/minute - she appears well. I discussed the symptomatic treatment of the cough per protocol and instructed the mother to call or return if the problem worsened.

Patient has no allergies to foods or history of reactions to past vaccines. I discussed the risks and potential side effects of the hepatitis B vaccine [...]