Pulmonology Coding Alert

The chief complaint and treatment plan can change everything Identify a significant, separate and unrelated problem before you report 99211 with immunization administration, or you may face denials.
 
Problem Justifies Separate E/M When determining whether you should bill 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) with 90465-90474 (Immunization administration ...), first look at the patient's history and vaccine administration details in your documentation.

"When the provider (usually the nurse) evaluates, manages and documents a complaint or problem, you can justify the additional reporting of CPT 99211," says Steven M. Verno, CMBSI, CMMC, CMMB, NREMTP, compliance director with the Medical Association of Billers.

To identify a standalone 99211, you can check for these bullets. The nurse typically:
  conducts a brief history,
  performs a chart review along with a physical assessment (such as indicated vital signs and observations),
  provides patient education in helping the family or patient manage the problem encountered. Key: "These nursing activities are all directly related to the significant, separate complaint, and are unrelated to the actual vaccine administration," Verno says. E/M, Procedure Notes Demonstrate 99211 If you can separate the E/M service and the vaccine administration, you can safely bill 99211. A separate nurse visit should include the following documentation details:   the date of service
  the reason for the visit (chief complaint or CC)
  a brief history of any significant problems the nurse evaluates or manages
  any examination elements (such as vital signs or appearance of a rash)
  a brief assessment and/or plan as developed after conferring with the physician along with any counseling or patient education
  signatures of the nurse and supervising physician. The nurse should record the above items in a separate entry from the vaccine documentation. The provider usually records the vaccine documentation product, lot number, site and method, vaccination sheet date, etc., on the immunization history document, Verno says. Different Diagnoses May Solidify Billable Service Looking at the diagnoses can help alert you to a service that may warrant coding a nurse visit. Additional diagnoses on the encounter sheet should trigger you to review the documentation. If appropriate, report 99211 with modifier 25, says Maria M. Torres, CPC, CMM, CCC, CMSCS, a primary-care consultant with Bermudez Medical Consulting Services in Tampa, Fla.

Why: Using different diagnoses helps show the payer that the nurse's service is medically necessary and separate from the vaccine administration. CPT, however, does not require you to report a separate ICD-9 code for the visit and the immunization administration.

Important: Do not use this guideline alone. Some insurers will only pay for certain vaccinations when the patients have associated underlying conditions that make the vaccination a [...]