Primary Care Coding Alert

Question: Our provider recently moved to a new electronic medical record (EMR), and I am getting an edit for a modifier on a 90471 vaccine administration charge when the provider administers a tetanus shot along with an evaluation and management (E/M). I am billing the E/M with modifier 25, which has never been a problem before. We are not getting an edit on influenza or pneumonia vaccine administration when billed this way with an E/M.

So, is the edit false? Have the regulations changed? Or is there a new Medicare G code I should be using like the administration codes for influenza, pneumonia, and hepatitis?

AAPC Forum Participant

Answer: The correct way to bill private payers for a tetanus shot is, as you say, to add 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) to the E/M using the appropriate level 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/ established patient …) providing you can document that the E/M is significant and separate. Per National Correct Coding Initiative (NCCI) edits, even though the E/M is a column 2 code to 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)), the edit pair have a modifier indicator of 1, meaning the edit can be overridden with an appropriate NCCI modifier (such as modifier 25) when appropriate.

The exception is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal). NCCI edits do not permit 99211 to be reported in addition to 90471, even if a modifier (such as modifier 25) is appended to 99211.

This suggests the EMR edit is false unless the E/M code you’re trying to report is 99211, especially as the regulations regarding the NCCI edit pairs have not changed.

However, if you are billing for Medicare, your billing for this scenario will be a little different. There is currently no G code for the tetanus vaccine administration. But you will need to append a Medicare-covered diagnosis code to the appropriate tetanus vaccine code from 90714 (Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use) or 90715 (Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use) and an administration code such as 90471.

That’s because Medicare will only cover the tetanus immunization under Part B if it’s part of a therapeutic regimen of an injury. Consequently, your documentation should contain an injury code to accompany the 90714/90715 and the 90471 to show that the patient is not getting the tetanus vaccine as a booster but as a result of being injured. For example, if the provider administered a tetanus shot because the patient cut his right thumb on a rusty can, you would append S61.011A (Laceration without foreign body of right thumb without damage to nail, initial encounter).