Wiki flu w/ E&M

[snjberry]

I have a provider who bills every immunization with URI or viral illness and only exam documentation is nose discharge. I also have an insurance co. telling me they will not pay because documentation doesn't support and that it's suspicious that every claim as stated above has URI/viral illness. I spoke with provider and told him he doesn't have enough documentation to support E&M but he continues to do so. I have also had parent complaints that child wasn't ill at time of service and questions as to why they are being billed. Please review the below note and tell me if you would bill E&M level w/ flu shot.
CC: flu booster
HPI:
Accompanied by: Parents
7 month female with URI symptoms, occasional cough. No f/v/d/r. Good PO, active. Continues to use bottle, beginning to use cup. Continues to gain weight nicely.

Current Medication:
None

Medical History:
Allergies/Intolerance:
lavendar - rash

Surgical History:
Denies Past Surgical History

Hospitalization:
Denies Past Hospitalization

Family History:
Social History:
ROS:

Objective:
Vitals:
Temp 99, HR 108, RR 28, Wt 14 lb 2 oz, Ht 27.25, BMI 13.37
Past Results:
Examination:
Pediatric Exam
GENERAL APPEARANCE: well nourished, well developed, NAD.
SKIN: no rashes.
HEAD: normocephalic.
EYES: sclera w/o injection.
EARS: TM's normal bilaterally.
NOSE: nasal discharge
ORAL CAVITY: moist mucus membranes, tonsils normal.
NECK: supple, full range of motion.
CHEST: good air exchange bilaterally, no grunting, retractions, pink in room air
HEART: no murmurs, regular rate and rhythm.
ABDOMEN: soft, no hepatosplenomegaly.
GENITALIA: deferred.
EXTREMITIES/BACK: all move well.
NEUROLOGIC EXAM: intact.
Physical Examination:
Assessment:
Viral illness - 079.99 (Primary)

Need for prophylactic vaccination and inoculation against influenza - V04.81
Plan:
Treatment:
Viral illness
Notes: Symptomatic care.
Need for prophylactic vaccination and inoculation against influenza
Notes: Immunization as noted.
Procedures:
Immunizations:
VFC - Influenza, trivalent, split, preservative free, 6-35 mo, IM : 0.25 mL given on Left Vastus Lateralis.

Disposition & Communication:
Next Appointment:
6 Weeks

Billing Information:
Visit Code:
99213 Office Visit, Est Pt., Level 3.

Procedure Codes:
90655 VFC - Influenza, trivalent, split, preservative free, 6-35 mo, IM. Modifiers: SL

90471 IMMUNIZATION ADMIN.

 

[mitchellde]

You would not give the flu vaccine to a symptomatic patient. So either the patient had the flu or they presented for the flu shot it cannot be both. Since the flu shot was administered and the exam does not look like a symptomatic patient, then it appears as though this was a visit for the flu shot, so bill only the injection and use dx code V04 for influenza immunization. However you need the document to clarify without the provider stating this was a flu shot encounter then I see nothing that can be billed here as it is contradictory at best.

 

[Squiabro]

flu with E/M

I agree with Debra. In addition, you should explain to the doctor that this has already red flagged (insurance carrier told you it looks suspicious) and there may be an audit of his claims. If the audit is unfavorable, he may face fines, penalties and repayment.

 

[snjberry]

Thank you both very much. When I speak with provider he states "well I've always done that and there's never been a problem", some providers are so set in old ways that getting them on board with correct coding is a struggle.
I continue to work on it.
Thanks again
Sandi CPC, CPMA

 

[MarcusM]

Your provider needs to be educated on electronic adjudication. In simple terms, everything is tracked, monitored, graphed, and tabulated. And once your provider has been "flagged" as a possible target for audit, then you cannot put the horse back in the barn. If your provider falls outside the bell curve, at some point, you can expect that knock on your door. And the penalties and fines are severe and can be extrapolated from just a few files, then applied to years of claims to come up with a monetary figure.