Accurate Diagnosis Coding for Immunization-Only Office Visits
Published on Mon Jun 01, 1998
There are times when an immunization is the only procedure a child needs. The best way to recoup your costs is to code for an office visit and an immunization, as covered in the January issue of PCA (pages 1-3). You should use CPT 99211 for an established patient (its not likely that you will give a new patient an immunization without a complete examination), and that will cover the costs of having a nurse give the shot. The example we used was DTaP, which would be 90700 and 99211.
Michael A. Fabrizio, MD, PC, of Pittsfield, MA, thinks this is a good idea, but wonders what diagnosis code to use. We would appreciate your input as this is something our office does frequently and we are not being reimbursed.
We know that some practices use the diagnosis code V20.2 when giving just an immunization. This is for a routine infant or child health check, and does include immunizations appropriate for age. However, this code is likely to cause you problems getting adequately reimbursed with many managed care plans, explains Angela Snyder, billing coordinator for Watson Salsbury Pediatrics, a part of the 28-pediatrician Capitol Area Pediatrics based in Fairfax, VA.
If the child comes in for a well visit at another time, then youre going to have two diagnosis codes for that checkup at different times, Snyder explains. Since insurance wont cover more than one well visit for a designated time period, it will automatically raise a red flag if you use the V20.2 diagnosis code twice within that period.
Snyder uses the prophylactic vaccination codes (see below) if the child didnt come in for a complete physical. For example, if a child comes in for a varicella shot, she would use 99211 for the first-level office visit, 90716 for the immunization, and the diagnosis code V05.4 for both CPT codes.
Its frustrating because every insurance is different, Snyder says. You have to do what each insurance company says [and reimburses for].
There are two basic ways that a child will get immunizations outside of a well visit. One is if the shots are deferred because the child has, say, an ear infection at the time of the well visit. When the child does come back for the shots, Snyder uses the appropriate procedure codes and diagnosis codes for the immunizations, and also uses a 99211. But for the date of illness, I put the date they were seen for the physical, says Snyder. Making it the same date helps prevent confusion on the part of many insurance companies, says Snyder.
Thats because even using the prophylactic vaccination diagnosis codes when immunizations are given as the only service, some insurance companies [...]
