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Newbie Needs Assistance

  1. Default Newbie Needs Assistance
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    Hi All

    I'm trying to assist a family member's family medical practice. I've signed up for the CPB course thru AAPC that starts in November. In the meantime, I was wondering if someone could assist me with the below.

    67 yo female presents to the office for labs. Wants the flu vaccine.

    Billing for . . .
    99214 office visit
    90472 immunization admin
    96372 therapeutic prophylactic injection
    1033F tobacco non-smoker (I know this isn't covered)
    4035F Influenza immunization recommended (probably not covered)
    3008F BMI (not covered)
    I think the Fs are for reporting purposes from what I've found.

    When I submit the above, I get the following . . .

    Code 99214 is a component of code 90472 but a modifier is allowed on 99214
    Code 99214 is a component of code 96372 but a modified is allowed on 99214
    The procedure code 90472 is defined as an add-on code
    The procedure code 90472 is invalid or requires a parent that is not on the claim

    I'm unsure when to add modifiers like 25, 59, QW, etc. When I add 25 modifier to 99214 I get
    The procedure code 90472 is defined as an add-on code.
    The procedure code 90472 is invalid or requires a parent that is not on the claim.

    Any assistance anyone could give would be greatly appreciated.
    TIA

  2. #2
    Default
    Based on the note listed:

    99214 office visit:
    If the reason for the visit is blood work and Flu vaccine, i'm not sure how they came up with level 4 E&M. There should be no E&M billed for just blood work with Flu Shot. E&M (99201-99215) requires a history, exam and medical decision making documented, separate from the work of the blood draw and vaccine. The documentation barely supports the vaccine admin. There is no mention of an E&M nor is there anything to show what blood work was done. If there is an E&M documented unrelated to the work required admin the vaccine or draw blood, then there should be a modifier 25 on the E&M code.

    90472 immunization admin: Actual code description is additional component (after the first) of a multi component vaccine (Think Measles, Mumps and Rubella which 3 vaccines combined into one vial). Flu shot is a single component vaccine so there is no reason for the code. Unless there is a vaccine not listed in your sample scenario)

    96372 therapeutic prophylactic injection: This is for drug that is not a vaccine. If its Medicare patient G0008 is for administration of Flu Vaccine, some payers may want 90471

    Codes that end with F are quality measure tracking. They should be $0 charge or if system doesn't accept zero charge should be a penny or two. Quality measures and how it effects bonuses is a specialty of it's own
    1033F tobacco non-smoker (I know this isn't covered)
    4035F Influenza immunization recommended (probably not covered)
    3008F BMI (not covered)

    I know you want to be helpful. I have a few years experience and I would be over my head in this situation. If the documentation you posted above is all there she may need to hire a trained professional. I responded here instead of the PM in case some others may have more advice to give.
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
    Contract/Fee Specialist - Remote

    20 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

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