Primary Care Coding Alert

Question: Our physician tried to bill an office visit (99213) along with codes for a vaccine (90715) and its administration (90471). His only diagnosis is V06.1 (Need for prophylactic vaccination and inoculation against combinations of diseases; diphtheria-tetanus-pertussis combined [DTP] [DTaP]). I think we should only bill the vaccines, even if he wants to report the office visit with a modifier. What do you recommend?

New Mexico Subscriber

Answer: First, the correct administration code depends on the age of the patient and whether the physician performed counseling during the encounter. If he only administered the vaccines -- with no counseling -- or the patient was older than 18 years of age, report 90715 (Tetanus, diphtheria toxoids and acellular pertussis vaccine [Tdap], when administered to individuals 7 years or older, for intramuscular use) and 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]).

If he did perform counseling and the patient was 18 years of age or younger, report 90715 with 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered). You would also include 90461 (...each additional vaccine or toxoid component administered [List separately in addition to code for primary procedure]) twice, because Tdap is a three-component vaccine; code 90460 covers the first component, and the two units of 90461 cover the other two components.

If you have no documentation of additional E/M services, you cannot submit 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...), with or without a modifier. Reporting an E/M service in addition to the vaccine administration will require appropriate documentation and a corresponding diagnosis that reflects the problem-oriented nature of the E/M service. Diagnosis V06.1 is not a problem-oriented diagnosis code.

Remember: The nurse practitioner, physician assistant, or physician can complete the counseling represented by 90460 and 90461. A registered nurse, licensed practical nurse, medical assistant, or other office staff does not qualify as a "qualified health care professional" who can offer counseling as a billable service under these codes.