This sometime gets tricky. Use this coding alert article for better understanding of the scenario.
When a child cannot be immunized during a well visit, perhaps because of an infection, and then returns to be immunized only, coders should bill using the immunization administration codes (90471/90472) instead of the nurse only visit, CPT 99211 .
Prior to the addition of 90471(immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration]; one vaccine [single or combination vaccine/toxoid]) and 90472 (each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]), pediatric coders used the nurse visit code 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician).
Now that the new codes are available (they were first issued in CPT 1999, but CPT 2000 improved on 90472 to make it for each subsequent vaccine rather than for two or more vaccines), it is important to use them.
But some practices are reluctant to use codes 90471/90472 because third-party payers sometimes present problems in terms of payment. (For more on this subject see the article, How to Fight the Bundling of Immunization Codes, page 6 of Pediatric Coding Alert January 2000). One of the biggest obstacles to the use of the codes is the fact that managed care thinks these services are included in the preventive medicine services visits. When 90471/90472 are used, managed care thinks its paying twice for administration, drawing down of vaccines, obtaining informed consent from the parents and record-keeping. When insurance companies refuse to pay for 90471/90472, many practices resort to 99211 instead, reasoning that at least this code pays. (See box on page 11 for ways to fight for reimbursement of 90471/90472.)
Pediatric coding experts say that you should use 90471/90472, despite the reimbursement challenge, for the following reasons:
1. Use code 99211 for minimal office visits. The nurse-visit code is for a sick visit, such as when a child needs a rapid strep test, explains Linda Walsh, MAB, the new senior health policy analyst at the American Academy of Pediatrics (AAP). If you are giving vaccines only at this visit, and you use 99211 with the V code for the vaccines instead of a sick code, insurance companies will say the codes dont match, says Walsh, who comes to her job from more than three years as office manager for a six-pediatrician practice.
2. Limiting well visits. Also if you use the V20.2 diagnosis code along with 99211 for the vaccines given on a separate day from the well visit, many insurance companies would reject the claim, saying that the child already had the well visit for that periodor worse, they would deny a subsequent well visit claim on the same grounds. Some plans, says Walsh, would even use this rationale if you used the individual vaccine V codes instead of the V20.2 codes. This would not happen if you used 90471/90472.
3. Nurse visit for documentation of problem. If a child is coming back for immunizations after a well visit, and the immunizations are the only thing being done, bill 90471/90472, urges Diana Arbes, CPC, reimbursement analyst for Childrens Hospital Pediatric Physicians, a 70-pediatrician department at the Oklahoma University Health Sciences Center in Oklahoma City.
But, if the nurse also is checking to make sure the upper respiratory infection is gone, for example, a 99211 also should be charged in addition to the administration codes. If it goes beyond that, with any kind of minimal documentation you would bill 99211, says Arbes. The ICD-9 code for 99211 should be the same as the original illness the child had that prevented the immunizations from being given during the well visit. And the ICD-9 codes for 90471/90472 should be the V codes for the vaccines.
Understanding Co-pay with 90471/90472
Whether you are billing 90471/90472, as you should be now, or 99211, as you probably were before the new codes, you need to be aware of what your contracts say about co-pays for these codes, says Richard H. Tuck, MD, FAAP, founding chairman of the American Academy of Pediatrics RBRVS PAC, and a pediatrician at PrimeCare Pediatrics in Zanesville, Ohio.
Contracts that dont allow co-pays with well visits would probably apply to the 90471/90472 as well. And for contracts that require co-pays on well visits and sick visits, the parent will already have paid the co-pay, so collecting it twice might not be allowed by the contract. Check with your contract, provider manual or provider relations person on co-pays.
For 99211, however, you would generally have to collect a co-pay. Laurie Castillo, CPC, president of Physician Coding and Compliance Consulting in Manassas, Va., says, Theres no co-pay except on E/M visits. But, Castillo says that its a good idea to check with health plans to see what their rules are, if its not spelled out in your contract (since these are relatively new codes). Theres no straight shot as far as immunization coding is concerned, she says. Some plans arent paying for administration at all.
Tip: Castillo recommends using 99211 with individual vaccine ICD-9 codes if your plan absolutely refuses to pay for immunization administration.