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
- Use 90460/90461
- 90460 is for the first COMPONENT of EACH vaccine
- 90461 is for the subsequent COMPONENT of EACH vaccine
- DTaP has 3 components, bill one unit of 90460 and two units of 90461
- 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
- 90471 is for the first VACCINE administered, regardless of the number of components
- 90472 is for the second/subsequent VACCINE administered, regardless of the number of components
- Vaccine was administered, patient has Medicaid, regardless of counseling
- Use the vaccine product’s CPT with a -SL modifier and bill at least $13
- 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)
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