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veloso

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260
Location
Beechhurst, NY
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Hi All,
Not a scheduled visit, patient wants 'flu vaccine' and as per MD order was given by RN provider charged 99213/25 with Flu Vaccine 90471/90658
Provider wants to bill 99213 because she did the following ;
1.) HPI
2.) Physical Exam
3. Flu Vaccine given

Needs assistance please!

Thank you!
 
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Where's the medical decision making? There's no chief complaint/problem to support an office visit. I'd say bill the flu shot only. Remind her of the requirements for E&M visits (as of 2021). She'll need a level of MDM or time in order to bill an E&M visit, and show medical necessity for the visit. What history was given? What did she examine and why?
 
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I agree with Pam Warren. Unless the patient had some preexisting contraindication which necessitated that the physician clear them first, that wouldn't require an OV first. Assuming it's the same in NY as here in VA, the patient could have easily walked into any pharmacy, filled out a simple form and received their flu shot. If some brief check was needed, then I would bill it as a 99212 at most.

Tom Cheezum, OD, CPC, COPC
 
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Hi,
Here is the brief progress notes MD asked if she could get credits because she did examine the patient?

General HPI:
General HPI 28 yo individual presenting for annual flu shot.
No acute concerns or complaints.
No hx of influenza vaccine reactions.

Review of Systems
General/Constitutional:
General General good general state of health, able to do usual activities, , no weight loss or gain.
Thorax:
Heart no chest pain or discomfort, no dyspnea on exertion, no heart murmurs. Lungs no SOB, no wheezing, no cough.
Musculoskeletal:
General FROM, no muscle pain, no trouble walking or climbing stairs.
Vital Signs
Temp: 98.2, HR: 67, RR: 15, BP: 110/73, Ht: 60, Wt: 160, BMI: 31.24, Oxygen sat %: 98.
Physical Examination
GENERAL:
Appearance: no acute distress, well-developed, well-appearing.
SKIN:
Skin: anicteric.
HEENT:
Head: normocephalic, atraumatic.
CHEST/LUNGS:
General breathing comfortably.
EXTREMITIES:
Tremors: No gross tremor.
NEURO:
Cranial Nerves: CN's II-XII grossly intact.
Gait: normal.
EYES:
Conjunctiva: unremarkable.
PSYCHOLOGY:
Affect: appropriate.
Eye Contact: normal.
Assessments
1. Encounter for immunization - Z23 (Primary)
Immunization
Influenza - Injection : 0.5 mL (Route IM)
Visit Codes
99213 Office Visit, Est Pt., Level 3.
Procedure Codes
3008F BODY MASS INDEX DOCD
90658 Vaccine
90471 IMMUNIZATION ADMIN
 
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My question would be what is the medical necessity of the office visit E&M service if the patient specifically came in for the flu vaccine? Just because a provider performed an exam doesn't mean it meets the overarching criteria for services to be billed to insurance, was it medically necessary? What was the medical necessity for the exam and corresponding E&M code?

The Medicine Section guidelines states the following:
If a significant separately identifiable evaluation and management service (e.g., new or established patient office or other outpatient services [99202-99215], office or other outpatient consultations [99242, 99243, 99244, 99245], emergency department services [99281-99285], preventive medicine services [99381-99429]) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes.​

What is significant and separately identifiable in this visit note that warrants an E&M, let alone a level 3 E&M?

I work for an insurance company and this kind of claim sends up all kinds of red flags based on the documentation you provided. It could get the provider on the fast track to being audited when the only DX billed is Z23 and the provider is billing an E&M in addition to the vaccine related procedures. This is just my opinion, if others see something I'm not seeing please don't hesitate to point it out to me. I'm open to hearing additional viewpoints or other reference sources that would change my opinion on this type of claim.
 
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I agree 99213 is CLEARLY overcoding. My opinion is to bill only the vaccine. It does go back to the overarching criteria of medical necessity. Only if the patient had other problems addressed would I consider billing 99213 along with the flu vaccine.
 
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Question: Does the provider know that exams aren't used to calculate the visit level any more? I wonder if some providers are setting themselves up for frustration by spending time on work (including documentation) that isn't strictly necessary any more and then finding out they aren't going to get paid for that work.
 
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jkyles said:
Question: Does the provider know that exams aren't used to calculate the visit level any more? I wonder if some providers are setting themselves up for frustration by spending time on work (including documentation) that isn't strictly necessary any more and then finding out they aren't going to get paid for that work.
Click to expand...
Good point! We usually don't see an exam done when patients come in strictly for flu vaccine, especially a 28y/o patient. The exam appears not to be medically necessary. No other problems addressed; E/M is not billable. It sounds like the provider is not aware of the new E/M guidelines that are based solely on MDM or time.
 
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