Travel Immunizations May Merit a Separate E/M
As seen in The Journal of Urgent Care Medicine, titled “Travel Immunizations:”
Q. What is the best way to code for and bill patients who come in because they are planning to travel out of the country and need to know what immunizations they should have before traveling? We advise them on preventive measures to take in relation to where they are traveling, provide literature if appropriate, and even try to find health-care facilities close to where they will be staying while abroad. I know we can bill for any vaccines that are administered, but can we also bill an evaluation and management (E/M) code?
A. You are correct that you can bill for any immunization(s) provided, as well as for the administration of the immunization(s). Bill the appropriate code in the medicine section of the Current Procedural Terminology (CPT) manual. For example, you verified that all routine immunizations are up-to-date except for tetanus, and on the basis of the destination of the patient, you discuss preventive measures to take regarding what foods and activities to avoid, how to self-treat minor ailments (such as diarrhea), provide information on medical facilities in the area and guidance on safe contact with animals indigenous to the area. You determine that the patient should receive the tetanus, yellow fever, typhoid, and polio vaccines. You would bill procedures as follows:
- 90715: “Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years and older, for intramuscular use”
- 90717: “Yellow fever vaccine, live, for subcutaneous use”
- 90690: “Typhoid vaccine, live, oral”
- 90713: “Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use”
- 90460: “Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered”
- 90461: “Each additional vaccine or toxoid component administered (list separately in addition to code for primary procedure)”
You will notice that the codes for the immunization administration include a counseling component. However, if you are researching information regarding the travel destination of the patient, offering guidance on which immunizations are needed and guidance on how to avoid sickness and injury while traveling, that is more counseling than is required for just administering those immunizations.
According to CPT guidelines, if you are seeing a patient for a visit and more than 50% of the time spent in the visit is attributed to counseling, you may select the visit level on the basis of the typical time shown for each level of visit:
- New patient E/M levels 1 through 5
- 99201: 10 minutes
- 99202: 20 minutes
- 99203: 30 minutes
- 99204: 45 minutes
- 99205: 60 minutes
- Established patient E/M levels 1 through 5
- 99211: 5 minutes
- 99212: 10 minutes
- 99213: 15 minutes
- 99214: 25 minutes
- 99215: 40 minutes
If the patient comes to the clinic only for counseling regarding immunizations required for foreign travel and preventive travel measures, then you might consider codes from the preventive medicine section of CPT:
- 99401: “Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes”
- 99402: “Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes”
- 99403: “Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes”
- 99404: “Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes”
As always, when the code you choose is based on time, that time spent must be documented, as well as what topics were discussed and the advice you gave. Please note that some payors deny these services as uncovered services. This is especially true for payors with urgent care contracts that specifically exclude preventative or primary-care services.
The diagnosis code(s) to use will be determined by the services performed in the clinic. If the patient received immunizations, you would use ICD-10 [International Classification of Diseases, 10th revision, Clinical Modification] code Z23, “encounter for immunization,” no matter how many immunizations were administered. This is one area where ICD-10 decreased the number of codes used to report the reason for the encounter. It was decided that one diagnosis code would be used to represent any immunization, as opposed to ICD-9 [International Classification of Diseases, Ninth Revision, Clinical Modification], where there were diagnosis codes that specified many different types of immunization, (i.e., V04.61, “need for prophylactic vaccination and inoculation against tetanus pertussis combined vaccine,” or V04.4, “need for prophylactic vaccination and inoculation against yellow fever,” etc.). If only counseling was provided and no vaccines were administered, you would just code Z71.89, “other specified counseling.”
Be sure to check with payors regarding their policies for any of these services.