Primary Care Coding Alert

Question: If our clinician administered a flu vaccination to a patient, is it possible for us to also report an E/M service for the same patient, or should I report only the vaccine codes and the administration codes?

Nebraska Subscriber

Answer: In general, you should not be reporting an E/M code for every patient that is coming in for a flu vaccination. Instead, you will have to look whether your clinician performed any significant and separately identifiable services in addition to the flu vaccine administration. Again, initial services that are normally performed prior to the administration of the vaccine, like recording of vital signs, brief history, and counseling, are generally considered part of the vaccine service and should not be reported with a separate E/M code.

You can report a separate E/M service code if and only if your clinician performed a separate and significant evaluation and management of the patient that was clearly distinct from the vaccination performed. For instance, if your clinician checks the patient’s blood pressure or his sugar levels and performs some adjustments to his medications that might warrant you to report a separate E/M code for the same visit in which you are reporting the flu vaccination.

When you look at Correct Coding Initiative (CCI) edits, you will see that there are bundling edits between CPT® vaccine administration codes, such as 90471, and E/M codes.  However, as the modifier indicator to these edits is ‘1,’ you can separately report the codes on the same calendar date of service if a suitable modifier is appended. As the E/M codes are the column 2 codes in the edits, you will have to append the modifier to these codes. The modifier that you will use to break the edit is 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).

Caveat: For any evaluation performed by a nurse, don’t report 99211 (Office or other outpatient visit for the evaluation and management of an established patient…) for the assessment of the patient when you are reporting an immunization code such as 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]). CCI edits between 90471 and 99211 carry the modifier indicator ‘0,’ which indicates that you cannot unbundle the codes and report the two codes under any circumstances. The same is true for 99211 and Medicare’s influenza vaccine administration code, G0008 (Administration of influenza virus vaccine). In any case, be sure to also report the code for the vaccine itself along with the code for its administration.