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Primary Care Coding Alert

3 Details Pinpoint Nurse Visit With Vaccine Admin Eligibility

Published on Thu Jul 07, 2005

Report unrelated complaint management as 99211

Reporting 99211 plus immunization administration will pass muster if you reserve the code for encounters involving a significant, separate problem unrelated to the procedure.

Recent American Academy of Pediatrics (AAP) guidelines on billing a nurse visit in addition to vaccine administration made the issue as clear as mud. "If we make an appointment, pull and prepare the chart, obtain a history, and prepare and administer the vaccine with chart documentation, should we bill for 99211?" asks Debbie Argo, office manager at Family Care of Kent in Kent, Wash.

Look for this information when determining whether you should bill 99211 with 90465-90474.

CC, Problem Justify Separate E/M

You should report a medically necessary E/M that is significant and separate from the immunization encounter. "When the provider (usually the nurse) evaluates, manages, and documents a complaint(s) or problem(s), you can justify the additional reporting of CPT 99211," says Steven M. Verno, CMBSI, CMMC, CMMB, NREMTP, compliance director with the Medical Association of Billers.

To identify a stand-alone 99211, you can check for these bullets. The nurse typically:
 

  • conducts a brief history
     
  • performs a chart review along with a physical assessment (such as indicated vital signs and observations)
     
  • provides patient education in helping the family or patient manage the problem encountered.

    Key: "These nursing activities are all directly related to the significant, separate complaint, and are unrelated to the actual vaccine administration," Verno says.

    Different Diagnoses Solidify Billable Service

    Looking at the diagnoses can help you spot a service that warrants coding a nurse visit. "Additional diagnoses on the encounter sheet should alert you to report 99211 with modifier -25," says Maria M. Torres, CPC, CMM, CCC, CMSCS, a primary-care consultant with Bermudez Medical Consulting Services in Tampa, Fla.

    Why: Using different diagnoses helps show the payer that the nurse's service is medically necessary and separate from the vaccine administration. CPT, however, does not require you to report a separate ICD-9 code for the visit and the immunization administration.

    E/M, Procedure Notes Demonstrate 99211

    If you can draw a line between the E/M service and the vaccine administration, you can safely bill 99211. A separate nurse visit should include the following AAP-recommended documentation: 

  • the date of service
     
  • the reason for the visit (chief complaint or CC)
     
  • a brief history of any significant problems the nurse evaluates or manages
     
  • any examination elements (such as vital signs or appearance of a rash)
     
  • a brief assessment and/or plan along with any counseling or patient education
     
  • signatures of the nurse and supervising physician.
     
    The nurse should record the above items in a separate entry from the vaccine documentation. The provider usually records the vaccine documentation product, lot number, site and method, vaccination sheet date, etc., on the immunization history document, Verno says.

    Nurse Visit Requires CC, Plan

    If you can identify a chief complaint and/or problem, an assessment and treatment plan, go ahead and bill a 99211 as this example shows:

    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.

    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 and append 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 intramuscular 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 intra-muscular use) linked to V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza)
     
  • immunization administration - 90471 linked to V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza).

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