Pulmonology Coding Alert

Question: A 70-year-old established patient with commercial insurance reports to the pulmonary practice to receive a pneumonia immunization. During history questioning, the patient tells the nurse she has been lethargic lately and has not been eating much. The nurse checks the patient's vital signs to make sure she can still tolerate the vaccine, then discusses how she can address her weakness and appetite problems. At that point, the nurse administers the injection. Can I report a separate E/M in this scenario? Minnesota Subscriber Answer: Since the nurse offered the patient counseling on a problem separate from the pneumonia vaccination (her lethargy and appetite problems), you should be able to report an E/M in addition to the immunization codes. On the claim, report the following: • 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to 2 years or older, for subcutaneous or intramuscular use) for the vaccine • 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the administration • V03.82 (Streptococcus pneumoniae [pneumococcus]) linked to 90732 and 90471 to prove medical necessity for the vaccination • 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) for the E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to show that the E/M and vaccination were separate services • 728.87 (Muscle weakness [generalized]) and 783.0 (Anorexia) linked to 99211 to represent the patient's lethargy and appetite problems. Medicare rules differ: If your patient has Medicare insurance, you would code the above encounter a little differently: Medicare and those payers that follow Medicare guidelines do not permit 99211 on the same claim with immunization administration codes. Only the physician or a qualified nonphysician practitioner (a nurse practitioner or physician assistant) may report an E/M-25 in addition to the vaccine.