Pulmonology Coding Alert

With the approach of fall, many patients are requesting flu and pneumonia shots as an insurance policy for the winter season. Other patients come into their pulmonology physicians office for a different reason, and a nurse or doctor suggests that a flu shot would be a good idea. This apparently small difference affects how you code for the vaccination.

Carol Pohlig, BSN, RN, CPC, reimbursement analyst at the Hospital of the University of Pennsylvanias Department of Medicine in Philadelphia, advises that the billings for the administration of the vaccine and the drug used are straightforward, but billing for evaluation of the patient (CPT 99211 ) is more complex.

Code 99211 is for an office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically five minutes are spent performing or supervising these services.

For all patients, youll bill for the administration of the injection. For Medicare and carriers that share the Medicare designations, use HCPCS level II code G0008 (administration of influenza virus vaccine when no physician fee schedule service on the same day) or G0009 (administration of pneumococcal vaccine when no physician fee schedule service on the same day). If your carrier doesnt use the Medicare designations, use the CPT code 90471 (immunization administration; single or combination vaccine/toxoid) for the flu and pneumonia administration. Pohlig warns, Use 90472 (two or more single or combination vaccines/toxoids) only if the flu and pneumonia vaccines are provided on the same date of service; otherwise, only 90471 would be reported for the single immunization.

Youll also bill one of these codes for the influenza vaccine: 90659, the whole virus; 90658, the split virus for 3-year-olds and older; 90657, the split virus for 6- to 35-month dosage; and 90660, the intranasally administered live virus.

Nancy DeMarco Lamare, CPC, CCS-P, a multispecialty coder for Central Maine Clinical Associates in Monmouth, Maine, says, The code 90669 is now Prevnar, the FDA-approved pediatric high-risk pneumonia shot. Its recommended for all children ages 2-24 months, children 2-5 years who have sickle cell disease, HIV, chronic disease, immunocompromising conditions, or who attended group child care. Use 90732 for pneumococcal polysaccharide vaccine, 23-valent, adult dosage, for subcutaneous or intramuscular injection.

Other Issues to Consider for Billing Flu Shot
And Evaluation

In some pulmonary care offices, Pohlig says, A patient comes in just for a flu shot. The nurse administers the injection, and the office thinks it can bill a 99211. But it cant unless the doctor or someone supervised by the doctor has evaluated the patient and performed a service that is separate and identifiable from the need for the vaccination.

The evaluation doesnt have to be extensive. For example, a patient may come in to see the nurse for a blood pressure check. While he or she is there, the nurse may suggest that its fall and its a good time for a flu shot. Then the office can bill for a 99211, Pohlig says.

If you bill a 99211 with the hypertension test, you need to attach modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the office visit and administering the flu shot were separate procedures.

Lamare explains it this way: CPT guidelines state that if a code already exists to describe a service performed, then that code must be used. This is the reason why a 99211 is not used for injections. For flu shots (90657, 90658) and pneumonia shots (90732), use the immunization administration code 90471 if the carrier isnt Medicare or for those that want the G codes to be reported.

But Lamare agrees that 99211 can be used in connection with a visit for another purpose. Code 99211 is primarily a five-minute nurse visit to cover services such as blood pressure checks or other minimal problems requiring an evaluation of the patients medical condition.