Wiki coding help - bill an E&M

[snjberry]

I see no reason to bill an E&M with this visit. It's for a 3yr old. What would you bill for this flu shot. Dr. wants 99212. If I take away all info on flu shot I have nothing left to bill.

Here for flu vaccine

History of Present Illness
here for influenza injection.

Current Medications
None
Allergies
N.K.D.A.

Review of Systems
General/Constitutional:
General ros neg other than as above.

Vital Signs
Temp 98.7, HR 103, BP not done, RR 18, SaO2 99, Wt 33.8, Ht 41, BMI 14.14, BMI Percentile 4.

Examination
General Examination:
GENERAL APPEARANCE: in no acute distress, pleasant, well groomed, well nourished.
HEENT: Head - normocephalic/atraumatic, tympanic membranes normal, clear conjuctiva, no conjunctival erythema, no discharge, nonicteric, Pupils Equal, Round, Reactive to Light (PERRL), Oropharynx clear with moist mucous membranes , pharynx and tonsils normal.
NECK/THYROID: no lymphadenopathy, supple.
CARDIOVASCULAR: regular rate and rhythm, no murmurs, click or rubs, no carotid bruits.
RESPIRATORY: clear to auscultation bilaterally, no wheezes, rhonchi, rales.
SKIN: no rash or skin lesions, no ecchymosis, normal temperature.

Assessments
1. Need for influenza vaccination - V04.81 (Primary)
Treatment

Immunization
Influenza, split, preservative free, 3 yrs & >, IM : 0.5 mL given by on RD

Procedure Codes
90656 FLU VACCINE NO PRESERV 3 & >
90471 IMMUNIZATION ADMIN

Disposition & Communication

Follow Up
prn

 

[Pam Warren]

There is no additional work done...no chief complaint other than the kid came in for a flu shot...no HPI indicating another issue, no exam findings relative to any issues, and there is no assessment/plan other than the flu shot. It would be inappropriate to bill an office visit for this along with the flu immunization.