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Internal Medicine Coding Alert

Reader Questions:
Reporting E/M With Vaccine Codes For New Patients? Not Always

Question: Our internist recently administered varicella vaccine to a new 23-year-old patient. The patient had no other problems or complaints. Our doctor took a brief history and family history prior to the administration of the vaccine. What codes should I report for the visit? Since the patient is a new patient to our practice, should I bill an E/M code in addition to the vaccine administration codes?

Texas Subscriber

Answer:  You should not report an E/M visit code just because your physician provided services to a new patient. You will have to base your decision on whether or not to report an E/M code for the visit based on why the patient came to see your clinician in the first place and on whether the services provided by your clinician would qualify you to report an E/M service independent of the vaccination or not.

In your case, your clinician only recorded a brief personal and family history, so this would not be enough to warrant you to report a new patient E/M service code, because those codes also require a level of exam and medical decision making that is missing from this encounter. The history taken by the provider will just be part of care that was provided prior to administration of the varicella vaccine and should not be reported separately. 

On the other hand, if the patient had an illness or condition that needed evaluation and management separate from the basic evaluation that your clinician did prior to the vaccine administration, you can look at reporting an E/M additionally. However, you will need a modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to the E/M code to let the payer know that both the services were separate and that the work of the E/M was over and above that typically associated with the vaccine administration.

You will have to report the vaccine administration with the CPT® code, 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) because only one vaccine was provided during the encounter. You will have to report the vaccine with 90716 (Varicella virus vaccine, live, for subcutaneous use). You will have to report V05.4 (Need for prophylactic vaccination and inoculation against varicella) and link it to the administration code and the vaccine code.