Primary Care Coding Alert

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, [...]