Primary Care Coding Alert

Question: One of our nurse practitioners (NPs) recently saw a 65-year-old established patient for a pneumonia vaccination. Before administering the vaccine, she takes a brief history, checks the patient's vital signs and rules out any contraindications for the vaccine. Can I report an E/M in addition to the vaccination codes?

South Carolina Subscriber

Answer: Probably not. From your description of the NP's actions, she did not do much beyond providing the evaluation and management inherent in the vaccine administration codes. For that reason, you should just report the vaccination codes.

On the claim, report the following:

- 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use) for the pneumonia vaccine.

- 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the vaccine admin.

Note: For Medicare patients, and those payers that observe Medicare rules, report G0009 (Administration of pneumococcal vaccine) for the vaccine administration rather than 90471.

- V03.82 (Need for prophylactic vaccination and inoculation against bacterial diseases; other specified vaccinations against single bacterial diseases; Streptococcus pneumoniae [pneumococcus]) linked to 90732 and 90471 (or G0009) to prove medical necessity for the service.

Explanation: The vaccine administration codes have an inherent E/M component (a brief patient assessment required before administering the vaccine) built into them. The E/M the NP provides the patient during the vaccin-ation must go beyond this inherent E/M in order to report a separate E/M code.

If you can identify a problem that the nurse assesses and separately treats (at the direction of the physician), you might be able to report an E/M service along with the immunization codes. So if the patient reports for a pneumonia vaccination and also asks the provider to check out a pain in her elbow, you might be able to report a separate E/M 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).

Warning: Code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) is bundled into injection services for Medicare beneficiaries (and beneficiaries of plans who follow Medicare guidelines).

So unless the provider's E/M exceeds a level-one service during an injection, you should leave the E/M code off the claim.