Primary Care Coding Alert

Question: I have been reporting flu vaccine with E/M visits and other in-office procedures. I have been using modifier 25 with these E/M codes, but some private insurance companies have been denying them. I bill the E/M with modifier 25 code first and then the flu vaccine

Tennessee Subscriber 

Answer: According to Correct Coding Initiative (CCI) edits, E/M office or inpatient codes are bundled into the vaccine administration codes 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), 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid])and 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]). CCI does not bundle E/M codes other than 99211 into the Medicare influenza vaccine administration code, G0008, however. 

However, the modifier indicator to this code bundling is ‘1’ which indicates that you can unbundle the codes using an appropriate modifier.The modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is appended to the E/M visit code. The exception to this rule is code 99211. The modifier indicator for the edits that bundle this code with all of the vaccine administration codes above is “0.” That means CCI edits never allow you to report 99211 for the same patient on the same date as a vaccine administration. 

Note:You should not report an E/M visit code if your FP only records a brief history, checks the patient’s vitals, and rules out any contraindications to the administration of the vaccine. Such a minimal assessment is likely to be considered part of the vaccine administration itself, which may explain why the CCI edits do not allow you to report 99211 in addition to a vaccine administration code. In such a case, you will only report the administration code and not an E/M code. You can report an E/M service with a vaccine administration code if and only if the E/M service was significant and separately identifiable from the vaccine administration as reflected in the physician’s documentation of the encounter.

As noted, you need to have proper documentation to justify the medical necessity and to prove that your FP actually provided a distinctly separate E/M service while also giving the patient a flu shot. In such a case, a different diagnosis code may help support separate payment ofthe office visit code. In any case, ICD-9 code V04.81 (Need for prophylactic vaccination and inoculation against other viral diseases; influenza) is mapped to the code for the influenza administration as well as the CPT® code for the influenza vaccine itself, which you should also report. If you are using ICD-10 codes, you will have to use Z23 (Encounter for immunization) instead of V04.81.