Wiki billing em with immunization event

[istanstu]

My practice has begun a new practice of requiring an office em(99212-99213) visit to be performed and billed for any patient receiving a vaccine. The chart has for example exam components. Cc of here for HPV vaccine and the diagnosis is always just the particular need for vaccination code ( v0489?) We also bill the vaccine CPR and the admin code of either 90471 Or 90460
I have stated that by appending a 25 modifier to the em we are bypassing claim edits and telling the payer to reimburse us for Em even though it isn't justified medically necessary. Has anyone else experienced this issue. Am I misunderstanding the Use of 25 mod. These specific examples are strictly to bring patient into office to receive vaccine but the new policy is requiring provider to document and perform an em service. Any suggestions

 

[mitchellde]

it is inappropriate to bill an E&M when the purpose of the encounter is to receive an injection either therapeutic or vaccine.

 

[MarcusM]

Your practice does not want to do this for many reasons...perhaps just run a vaccination clinic periodically to get all of these done in one clinic time. I would schedule a vaccination clinic on one of our off afternoons, and have 25 patients come in within a one hour time frame and line them up and get it done. It was quick and easy and the patients loved it...no sick visits, no preventive visits, just vaccinations. And for Modifier 25, please see this below:

Modifier 25 Fact Sheet

Definition
Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure
*Same physician - Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician." The same physician concept also applies when the exact same physician performs services.

All E/M services provided on the same day as a procedure are part of the procedure and Medicare only makes separate payment if an exception applies.

Appropriate Usage
Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
Use Modifier 25 with the appropriate level of E/M service.
The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File.
An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.)
Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service.
Inappropriate Usage
A physician other than the physician* performing the procedure.
Documentation shows the amount of work performed is consistent with that normally performed with the procedure.
The following statements are false

I can always use this modifier for a new patient.
I can always use this modifier when I did not plan the procedure.
I can always use this modifier when the diagnoses are different.
I can never use this modifier when the diagnoses are the same.
Procedure codes:

G0181-G0182 Care Plan Oversight Supervision
92002-92014 E/M Ophthalmology
99201-99499 E/M all locations