pedscoder21
Guru
Our physicians LOVE to bill e/m's for immunization visits (for example, a healthy child presenting to the office for the flu vaccine - that's it; the physician will bill the administration of the flu vaccine along with 99212 
). We have been deleting the e/m and have told them over and over that this is wrong when the child is healthy with no complaints.
Unfortunately, some of the docs do not take our word and say that the reasoning for billing an e/m was because they did a physical and documented the history of the patient to ensure he/she is ok for the vaccine that day. They also say this for new patients, "we don't know the kid so we spend more time reviewing their history and physical exam."
We even went as far as contacting the AAP (giving an example of a healthy new patient), in hopes that the physicians would then take our word for it. Here is the AAP's response:
Note that CDC does not require an exam prior to the administration of vaccines, so there is the issue of medical necessity. Remember that to report an initial new patient code, you have to have history, exam and MDM. In the history part, HPI is required and there is no ?illness? - unless the patient has any medical conditions you are addressing, you will never get past a 99201. However, you have to be sure that you meet all 3 required in a 99201. Again, for someone with no current illness or history of a chronic condition that requires addressing at the encounter, you are left with ICD-9-CM code V68.89 (encounter for administrative purposes) for ICD-10-CM report Z02.89 (Encounter for other administrative examinations). That also creates an issue because the ICD-9 code may not support the CPT reporting.
I would love to hear anyone's response on this topic.
). We have been deleting the e/m and have told them over and over that this is wrong when the child is healthy with no complaints.Unfortunately, some of the docs do not take our word and say that the reasoning for billing an e/m was because they did a physical and documented the history of the patient to ensure he/she is ok for the vaccine that day. They also say this for new patients, "we don't know the kid so we spend more time reviewing their history and physical exam."
We even went as far as contacting the AAP (giving an example of a healthy new patient), in hopes that the physicians would then take our word for it. Here is the AAP's response:
Note that CDC does not require an exam prior to the administration of vaccines, so there is the issue of medical necessity. Remember that to report an initial new patient code, you have to have history, exam and MDM. In the history part, HPI is required and there is no ?illness? - unless the patient has any medical conditions you are addressing, you will never get past a 99201. However, you have to be sure that you meet all 3 required in a 99201. Again, for someone with no current illness or history of a chronic condition that requires addressing at the encounter, you are left with ICD-9-CM code V68.89 (encounter for administrative purposes) for ICD-10-CM report Z02.89 (Encounter for other administrative examinations). That also creates an issue because the ICD-9 code may not support the CPT reporting.
I would love to hear anyone's response on this topic.