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Pediatric Coding Alert

Nurse Visit Documentation Must Include 6 Items

Published on Wed Feb 16, 2005

Look for CC, problem to justify separate E/M service from administration

Train staff to report a nurse visit in addition to vaccine administration when a patient chart contains these six bullets.

Immunization administration encounters that involve patient problems and evaluations justify CPT 99211-25 (Office or other outpatient visit for the evaluation and management of an established patient ...; Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with 90471-90474 (Immunization administration ...). The nurse "evaluates, manages, and documents the significant and separate complaint(s) or problem(s)," states the American Academy of Pediatrics Committee on Coding and Nomenclature in its paper "When Is It Appropriate to Report 99211 During Immunization Administration."

You'll know exactly what you need to bill a nurse visit with immunization administration. "The paper has more details as to what is needed for documentation," says Maria M. Torres, CPC, CMM, CCC, CMSCS, a primary-care consultant with Bermudez Medical Consulting Services in Tampa, Fla.

Because it's an "incident-to" service, 99211-25 documentation should include:
 

  • the date of service
     
  • the reason for the visit
     
  • a brief history of any significant problems that the nurse evaluates or manages
     
  • any examination elements (such as vital signs or appearance of a rash)
     
  • a brief assessment and/or plan along with any counseling or patient education the nurse performs
     
  • signatures of the nurse and supervising physician.

    Tip: Looking at the diagnoses can help you spot a service that warrants coding a nurse visit. "Additional diagnoses on the encounter sheet should alert you to report 99211 with modifier -25," Torres says.

    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.

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