Practice Management Alert

A separate E/M is sometimes possible--if you know what to look for

Encounters for flu-shot vaccinations often last only long enough for the physician or nurse to administer the vaccine.

However, there are some flu-shot encounters that take longer, if a patient has other health issues he wants the doctor to address.

When? During the flu-shot encounter, if the physician treats the patient for a problem that is separately identifiable from the flu shot, a valid claim might include an E/M service in addition to the flu-shot codes, says Vickie Jackson, practice administrator for Southern Orange County Pediatrics in Lake Forest, Calif. 

Payoff: If your physician provides a flu-shot vaccination and separate care for an unrelated issue during the same encounter, you may be able to bill the shot and a separate evaluation and management (E/M) code.

But before billing a separate E/M, be sure that the E/M service was separate from the flu vaccination. If a physician provides E/M service related to the vaccination, then the service is considered a component of the flu shot.

Problem: Think about how you would bill the following flu shot-E/M service combination:

An established patient with commercial insurance comes in with a complaint of neck pain. The physician performs a level-two E/M service on the patient for his pain, then reminds him that the flu vaccine is in. The patient gets a preservative-free flu vaccination via intramuscular injection.

Solution: On the claim, a biller should report the following, Jackson says:

- bill 90656 (Influenza virus vaccine, split virus, preservative-free, for use in individuals 3 years of age and above, for intramuscular use) for the vaccine type.
 
- bill 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the vaccine administration.

- attach V04.81 (Need for prophylactic vaccination against certain viral diseases; other viral diseases; influenza) to 90656 and 90471 to show that this was a flu vaccination.

- bill 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making) for the E/M service.

- attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99212 to show that the E/M service was for an issue not related to the flu shot.

- attach 723.1 (Other disorders of cervical region; cervicalgia) to 99212 to show that the doctor performed the E/M service because of the patient's neck pain.
 
Remember: If the patient has an appointment for the flu shot only, or the office is conducting a -shot clinic,- then a patient's flu-shot bill should only include codes for the vaccine type and administration, Jackson says.