Pulmonology Coding Alert

Although reporting the flu vaccine administration and drug used is straightforward, billing a patient evaluation (99211) during the same visit is more complicated.

With the approach of fall, many patients are requesting flu and pneumonia shots as an insurance policy for the winter season. Other patients come into their pulmonary physician's office for an unrelated reason, and a nurse or doctor suggests that a flu shot would be a good idea. This apparently small difference affects how you code for the vaccination.

Code 99211 is for an office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal, and the pulmonologist spends about five minutes performing or supervising these services.

For all patients, you should report the administration of the injection. For Medicare and carriers that follow Medicare guidelines, you should use G0008 (Administration of influenza virus vaccine when no physician fee schedule service on the same day) or G0009 (Administration of pneumococcal vaccine when no physician fee schedule service on the same day). If your carrier does not follow Medicare, use 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]) for the flu or pneumonia administration. You should use +90472 (& each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) only if the flu and pneumonia vaccines are provided on the same date of service. Otherwise, only 90471 would be reported for the single immunization.

Remember, CPT identifies 90472 as an add-on code and, as such, it cannot be billed without reporting 90471 first. You would not need to append a modifier (e.g., -51, Multiple procedures) to 90472 because this procedure code does not stand alone and is an additional portion of another procedure. Also, G0008 and G0009 may be reported in addition to the immunization code (e.g., 90657, Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use) and the E/M service despite the code's descriptor stating, "when no physician fee schedule service on the same day."

Conversely, 90471 and 90472 cannot be reported or reimbursed if performed on the same day as an E/M service. The codes have a "T" status in the Federal Register, which means these services are not payable when reported on the same day as another service that is payable under the Physician Fee Schedule. Therefore, you could report only the immunization code and the E/M service.

You should also bill one of these codes for the influenza vaccine supply: 90657; 90658 (Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use); 90659 (Influenza virus vaccine, whole virus, for intramuscular or jet injection use), or 90660 (Influenza virus vaccine, live, for intranasal use).

Code 90669 (Pneumococcal conjugate vaccine, polyvalent, for children under five years, for intramuscular use) is now Prevnar, the U.S. Food and Drug Administration-approved pediatric high-risk pneumonia shot. It is recommended for all children ages 2-24 months, children 2-5 years who have sickle-cell disease, HIV, chronic disease, immunocompromising conditions, or who attended group child care. You should use 90732 for pneumococcal polysaccharide vaccine, 23-valent, adult dosage, for subcutaneous or intramuscular injection.

In some pulmonary offices, a patient comes in just for a flu shot. The nurse administers the injection, and coders may believe they can report 99211. But they cannot unless the pulmonologist or someone supervised by the physician evaluates the patient and performs a service that is separate and identifiable from the need for the vaccination.

The evaluation does not have to be extensive. For example, a patient may come in to see the nurse for an educational review of their asthma medication regime. While he or she is there, the nurse may suggest that this would be a good time for a flu shot. Then the office can bill 99211.

If you report 99211 with asthma (493.xx), you should attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the office visit and administering the flu shot are separate procedures.

If the pulmonologist performs the evaluation, it is likely to be more thorough, says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues in Fountain Valley, Calif. "Consequently, you would likely report a higher-level E/M code (e.g., 99212) for the physician's services, providing there is documentation to support it," Tucker says.

Under certain circumstances, however, the E/M service does not have to be for an unrelated condition, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm based in Lansdale, Pa. "If the patient comes in for the flu shot and develops some immediate sort of reaction to the shot, then, depending on the extent of the circumstances, the nurse may address the allergic reaction, or the physician and/or nurse practitioner may intervene."

If the nurse addresses the situation, you should bill 99211, Falbo says. If the physician or nurse practitioner intervenes, the service may warrant a higher E/M level. "The acid test is as follows: Outside of the flu shot, is there sufficient documentation of a history, exam and medical decision-making to warrant billing for a separate evaluation and management service," Falbo asks. "Is the medical necessity of the additional service clearly indicated in the progress note?"

If it is, you should bill the additional service and remember to append modifier -25 to the E/M code and link the appropriate diagnosis code to the E/M service and injection. "After having performed the service, linking the diagnosis codes to the appropriate CPT codes demonstrates the medical necessity of the service and increases the likelihood that the service will be paid appropriately," Falbo says.

Identifying a separate diagnosis for the E/M service can be helpful when reporting an E/M service and vaccine administration during the same visit. The flu or pneumonia shot should be reported with V04.8 (Need for prophylactic vaccination and inoculation against certain viral diseases; influenza) or V03.82 (Need for prophylactic vaccination and inoculation against bacterial diseases; streptococcus pneumoniae [pneumococcus]), respectively.

And, some insurers will reimburse only if the patient is viewed as "high risk" for developing flu or pneumonia and want you to report the conditions that warrant the need for immunization, e.g., chronic obstructive pulmonary disease, 496. If the E/M service can be reported with a sign, symptom or condition (i.e., a related or unrelated problem that is addressed during the visit), this typically constitutes a separate and identifiable service.