Disclaimer: I am not a certified coder. I’m not a biller. I’m a self-taught provider and I do my own coding and have done my own billing in the past.

When I graduated, I had only a rudimentary grasp on coding, and no real understanding of the life cycle of billing. Each specialty has its own subtleties around coding, but most providers bill a combination of evaluation and management (E&M) codes, procedures, and products (like vaccines or medications).

CPT Coding

New Patients and Consults

Code/Time	MDM	History       AND	Exam	Consults
99201  10	Straight	CC, HPI 1-3 qualifiers (brief HPI)	1 system	99241  15
99202  20	Straight	CC, HPI x 1-3, ROS x 1 system	2—4 systems	99242  30
99203  30	Low	CC, HPI x 4, ROS x 2 systems, at least 1 Hx	5—7 systems	99243  40
99204  45	Moderate	CC, HPI x 4, ROS x 10, PMFS (3 Hx)	8+ systems	99244  60
99205  60	High	CC, HPI x 4, ROS x 10, PMFS (3 Hx)	8+ systems	99245  80

Established Patients

Code/Time	MDM	History                           OR	Exam
99212  10	Straight	CC & HPI 1-3 qualifiers (brief HPI)	1 system
99213  15	Low	CC, HPI x 1-3, ROS x 1 system	2—4 systems
99214  25	Moderate	CC, HPI x 4 (or 3+ chronic diseases), ROS x 2 systems, PFSH (1 Hx)	5—7 systems
99215  40	High	CC, HPI x 4 (or 3+ chronic diseases), ROS x 10, PMFS (3 Hx)	8+ systems

Two of the three components – history, exam, medical decision making – are required.

Modifiers

-25 well visit + illness

-25 E&M + surgery

-24 visit that is not included in global, despite being within the global procedural timeframe (varies by procedure)

-63 procedure on baby under 4 kg

-95 telemed

House Calls – New Patient

Code/Time	MDM	History                           AND	Exam
99341  20	Straight	Problem-focused history	Problem-focused
99342  30	Low	Expanded problem-focused history	Expanded problem-focused
99343 45	Mod	Detailed history	Detailed
99344 60	Mod	Comprehensive history	Comprehensive
99345 60	Mod	Unstable patient

House Calls – Established Patient

Code/Time	MDM	History                           OR	Exam
99347  15	Straight	Problem-focused history	Problem-focused
99348  25	Low	Expanded problem-focused history	Expanded problem-focused
99349 40	Mod	Detailed history	Detailed
99350 60	Mod	Comprehensive history. Unstable/immediate attention required.	Comprehensive

Extended Services

Code
99354	Prolonged services, first hour
99355	Prolonged services, each additional 30 min
99050	Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service

Preventive Care:

99381        PREV VISIT, NEW, INFANT

99382        PREV VISIT, NEW, AGE 1-4

99383        PREV VISIT, NEW, AGE 5-11

99384        PREV VISIT, NEW, AGE 12-17

99385        PREV VISIT, NEW, AGE 18-39

99386        PREV VISIT, NEW, AGE 40-65

99387        PREV VISIT, NEW, 65 & OVER

99391        PREV VISIT, EST, INFANT

99392        PREV VISIT, EST, AGE 1-4

99393        PREV VISIT, EST, AGE 5-11

99394        PREV VISIT, EST, AGE 12-17

99395        PREV VISIT, EST, AGE 18-39

99396        PREV VISIT, EST, AGE 40-64

99397        PREV VISIT, EST, 65 & OVER

Z00.110     Health examination for newborn under 8 days old

Z00.111     Health examination for newborn 8 to 28 days old

Z00.129     Encounter for routine child health examination without abnormal findings

Z00.121     Encounter for routine child health examination with abnormal findings

Z23             Encounter for immunization

In Washington, vaccines are paid for by the Washington Vaccine Association (WVA), distributed by the county Vaccines for Children programs, administered by the provider, who then submits a claim to the insurance company to reimburse the WVA. This saves providers from having to purchase vaccines up front. When you bill for a well child visit, you bill the E&M and vaccine counseling and administration on your own behalf, and submit a second claim with the vaccine product codes to the payer on behalf of the WVA (with their tax ID and pay-to address). http://www.wavaccine.org/wavaccine.nsf/pages/for-providers.html walks you through that.

There are 3 scenarios for billing vaccine administration:

• Provider counseled and vaccine was administered – eg vaccines given during a well-child visit, questions answered
  1. Use 90460/90461
  2. 90460 is for the first COMPONENT of EACH vaccine
  3. 90461 is for the subsequent COMPONENT of EACH vaccine
  4. DTaP has 3 components, bill one unit of 90460 and two units of 90461
  5. DTaP-Hib-Polio has 5 components (one first, 4 subsequent)
• No counseling, vaccine was administered – eg vaccines given during a vaccine-only MA visit, or there was no discussion about the vaccines
  1. 90471 is for the first VACCINE administered, regardless of the number of components
  2. 90472 is for the second/subsequent VACCINE administered, regardless of the number of components
• Vaccine was administered, patient has Medicaid, regardless of counseling
  1. Use the vaccine product’s CPT with a -SL modifier and bill at least $13
  2. No administration codes

SCENARIO 1: 4-month well child visit, also has a serious diaper rash. Gets all the typical vaccines, plus you prescribe mupirocin ointment. Spent an hour, 15 minutes in excess of routine on the diaper rash.

CPT                                                                                                                ICD10

E&M

99391-25 for the well child w/ abnormal findings                     Z00.121 – don’t include the vaccine diagnoses or the rash diagnosis

99213-25 for the diaper rash                                                              L22

You need the -25 on both because there are 2 E&M codes, and because the vaccine codes have counseling in them, which somehow counts as E&M as well. You bill the 99213 because there was significant management around a second issue, e.g.  a referral or prescription. The 25 goes in the modifier box. They will likely owe a copay on the second E&M if insurance covers it, but many don’t pay that second code. You don’t include the Z23 on the well child CPT because then they’ll say that your well child counseling included the vaccine counseling and won’t pay you for the vaccine counseling codes.

Vaccines

Pentacel (DTaP-Hib-Polio)                                                                    Z23

90698 – DTAP-HIB-IP VACCINE, IM                                                   the vaccine itself
90460 – IMADM ANY ROUTE 1ST VAC/TOX                                  admin and counseling of first component
90461 – INADM ANY ROUTE ADDL VAC/TOX                               admin and counseling of subsequent component
90461 – INADM ANY ROUTE ADDL VAC/TOX                               you can either put the code down 4 times, or the code with 4 units
90461 – INADM ANY ROUTE ADDL VAC/TOX
90461 – INADM ANY ROUTE ADDL VAC/TOX

Rotavirus (RotaTeq)

90680 – ROTAVIRUS VACC 3 DOSE, ORAL                                      Z23
90460 – IMADM ANY ROUTE 1ST VAC/TOX                                  Z23

PCV13 (Prevnar)

90670 – PNEUMOCOCCAL CONJUGATE VACCINE 13-VALENT                    Z23
90460 – IMADM ANY ROUTE 1ST VAC/TOX                                                      Z23

Once you create the claim, the vaccine product CPTs will get split off into a second claim with a price of 0.01. Athena will adjust the price and then send it for reimbursement to the WVA. The administration codes stay on the primary claim so that we get paid.

SCENARIO 2: Same as above, but the kiddo is on Medicaid.

CPT                                                                                                                ICD10

E&M

99391-25 for the well child                                                                  Z00.129, Z23

99213-25 for the diaper rash                                                              L22

You bill the 99213 because there was significant management around a second issue, e.g.  a referral or prescription. You probably don’t need a -25 on the 99213 because there’s no counseling/administration code for the vaccines, but may as well include it.

Vaccines

Pentacel (DTaP-Hib-Polio)                                                                    Z23

90698,SL – PENTACEL (DTAP-HIB-IPV) (STATE SUPPLIED)

Rotavirus                                                                                                     Z23

90680,SL – ROTAVIRUS VACCINE (5-VALENT) (STATE SUPPLIED)

PCV                                                                                                                Z23

90670,SL – PCV13 (STATE SUPPLIED)

In this scenario, the vaccines will have real prices, and we’ll get $5.96 $16.27?! (increased as of Oct 1, 2018). Don’t use separate administration codes. The vaccines will not get split off into a second claim. You must do the CPT,SL in the same box. Because pricing is affected, the SL does NOT go in the modifier box.

SCENARIO 3: Parent of new baby wants a Tdap. Write up a short chart note. You take the vaccine from my private supply and give him a Tdap. If they’re an established patient, great, otherwise ask the parent to check in with the front desk and register the parent real quick. You don’t need to do a whole new patient visit, just make sure they’re ok to get the vaccine and give it.

E&M

Generally no E&M code. Then later you can do a new patient visit if they do establish.

Vaccines

90715 – TDAP VACCINE >7 IM
90471 – IMMUNIZATION ADMIN                                                      never any vaccine counseling codes for adults

Make sure there’s a real price on any adult vaccines, since we paid for them and need to get paid back for them.

SCENARIO 4: Baby is due for a bunch of vaccines but they decline them all. You spend 20 minutes talking to them about vaccines but they continue to decline.

E&M

Well child w/ abnormal findings                                                       Z00.121 + Z28.82 immunization not carried out because of caregiver refusal

You can decide whether to code a second E&M for the excess counseling, depends on the family. If you do it, apply the immunization not carried out diagnosis to that CPT.

Office visits scenarios:

SCENARIO 5: Baby (8mo) comes in with a rash, plus you give him a flu vaccine. Time: 30 minutes.

99214-25                      diagnosis: rash (pick the right kind), need for flu immunization Z23

90655 – FLU VACCINE NO PRESERV 6-35M                diagnosis: Z23
90460 – IMADM ANY ROUTE 1ST VAC/TOX              diagnosis: Z23

Note that each vaccine product has its own CPT code, and there are a lot of different flu vaccine products (baby injection, big kid injection for kids who have asthma or can’t get live vaccine, big kid nasal mist, etc), so make sure it’s the right product and subsequently the right CPT.

SCENARIO 6:  Big kid has a cough and conjunctivitis. Time: 15 minutes.

99213                            diagnosis: cough, conjunctivitis

MA visit scenarios:

With MA vaccine visits, there is no counseling, there is only administration.

For private insurance, use 90471 for the first injection (or oral/nasal administration), and 90472 for each subsequent injection.

For Medicaid, use only the vaccine product code with the SL modifier, and no administration code.

PRIVATE INSURANCE: A kid comes in for vaccines with the medical assistant. She gets Hep B and Hep A. She has private insurance.

E&M

No visit/E&M code

Vaccines

Hep B:

90744 – HEPB VACC PED/ADOL 3 DOSE IM
90471 – IMMUNIZATION ADMIN                                                      administration of first vaccine, no counseling

Hep A:

90633 – HEP A VACC, PED/ADOL, 2 DOSE
90472 – IMMUNIZATION ADMIN, EACH ADD                               administration of second vaccine, no counseling

MEDICAID:

E&M

No visit/E&M code

Vaccines

Hep B:

90744,SL – HEPB VACC PED/ADOL 3 DOSE IM (STATE-SUPPLIED)

Hep A:

90633,SL – HEP A VACC, PED/ADOL, 2 DOSE (STATE-SUPPLIED)