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encounter for immunizations

  1. #1
    Default encounter for immunizations
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    Ok pt came in for immunization for school (17yrs) first dos received to vaccine it was coded 99394 with v70.0. pt return for follow-up received another vaccine they coded 99213 with v70.0. Is this correct or she they have used v20.2.

    thanks
    Last edited by perkins05; 12-15-2010 at 12:45 PM.

  2. #2
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    Immunization admin code, depending on the age of pt and how immunization was given -

    If the patient was over 8 years old, 90471 for the first vaccine, if it was a shot, or 90473 for the first vaccine, if it was oral or nasal, and each additional vaccine administration would be either 90472 (IM) or 90474 (oral/nasal).

    If they were under 8 years old, see codes 90465 - 90468.

    Also, you may bill the vaccine substance itself - like influenza, 90658.

    Do not bill an office visit in this situation, because no significant/separately identifiable problems were addressed during the encounter.

  3. #3
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    Rules clarified...

    If they only came in for immunizations, and no history or exam was taken, no office visit should have been billed at all. You would especially not bill an office visit of 99213 with a routine diagnosis, like V700 or V202. V202 is routine child health exam, so technically, it can be used until age 18, but we typically don't use it past age 8, mainly due to payer definitions of well child care.

    V70.3 is for a general medical exam for school admission.

    You only bill an office visit when the key components are met during the visit. For a preventive (like 99394), there has to be an age appropriate comprehensive history and exam taken in addition to any counseling or immunizations.

    For problem oriented, such as 99213, you must have specific elements of patient history (ROS, HPI, Chief Complaint, PFSH), and a physical exam, as well as medical decision making based on the presenting problem, diagnostic options, treatment options, and risks involved to qualify the visit for each E/M level. See CMS's documentation guidelines for further explanation.
    Last edited by btadlock1; 12-15-2010 at 12:58 PM. Reason: More specificity...

  4. #4
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    Thanks very much for your assistance. So the 90471,90746 can stand alone without and encounter e/m code?
    they also used 4040f and G8427

  5. #5
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    Yes, they sure can! You may make the patient a happy camper, also, since many payers don't require a copay on immunizations. You're not required to bill an E/M service, and it would be inappropriate to report one if the services the codes are describing were technically not performed. It really all boils down to how much was documented, though. There could very well be enough info there to support billing a preventive E/M visit, but I'd have to see the whole note to tell you for sure. I can tell you, though, that if no history or exam whatsoever is documented, you'd be better off not billing an E/M code at all. Hope that helps!

  6. #6
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    ok...here is the note...please tell me what you think...
    17 yr for immunization for school

    ROS
    fever, patient denies painful respiration, dyspena,cyanosis,vomiting,diarrhea
    last eye exam 4/08
    vitals, BP, BMI,

    Exam
    non-ill , no apparent distress
    neck supple
    ear canals clear, tympanic membranes intact
    oropharynx is benign
    chest is clear auscultation/percussion
    heart rhythm normal s1 and s2
    ab-soft non tender no hematosplenomegaly
    MS-no swollen joints

    Plan
    medications review and updated
    Immunizations ordered
    varicella & adacel/tdap

    f/u 1 month

  7. #7
    Default
    99394 (V70.3, V70.0 or V20.2 are all fine as a primary diagnosis- I'd personally go with V70.3 because it's the most accurate.) I'd also code V06.1 and V05.4 on the office visit.
    90715 V06.1
    90716 V05.4
    90471 V06.1
    90472 (Assuming vaccines were administered separately) V05.4

    Keep in mind, though, my background is commercial insurance, so the CPT codes used for Medicare or Medicaid may not be the same.

  8. #8
    Default
    Thanks...I guess the follow-up is what the payer must have a problem with because we used 99213 for visit with v70.0 again
    ok...here is the note...please tell me what you think...
    17 yr f/up hep b
    pt told by school needs 1 hep b injection to be complete

    ROS
    fever, patient denies painful respiration, dyspena,cyanosis,vomiting,diarrhea
    last eye exam 4/08
    vitals, BP, BMI,

    Exam
    non-ill , no apparent distress
    neck supple
    ear canals clear, tympanic membranes intact
    oropharynx is benign
    chest is clear auscultation/percussion
    heart rhythm normal s1 and s2
    ab-soft non tender no hematosplenomegaly
    MS-no swollen joints

    Plan
    medications review and updated
    Immunizations ordered
    hep b given

    f/u 6 month

  9. #9
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    Here's where it's going to get complicated - Most insurers only cover a limited number of well checks for a given time period (usually one per year once they reach age 2). Your dates of service will matter. How much time had passed from the first visit to the second one? There's no documentation supporting a problem-oriented E/M, so scratch the 99213 now. You can bill another routine visit, but it's going to deny. The question is, will it deny for medical necessity (since the patient JUST had a routine exam, and really all they needed was the additional vaccine), or will it deny as exceeding the patient's benefit maximum for routine services. I wouldn't bill an office visit, personally, because the full workup wasn't needed. I would have just billed 90471 and 90746.

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