A few weeks ago, a colleague gave me an interesting dilemma. One of her providers, a pediatrician, wanted to bill a 99212 with vaccines even when the patient did not see the doctor. Since the medical assistants spent some time counseling the patient, the doctor wanted to make sure the practice was paid for that time. My colleague’s question was whether or not a 99212 would be acceptable to report to the insurance company in that manner.
Well, short story shorter, the only office visit we can bill when the provider does not see the patient is a 99211. E&M University has an excellent breakdown of the requirements for each of the codes.
The requirements for a 99212 include a problem focused history, a problem focused exam, and straightforward medical decision making. While the MA’s can take the history, the only person medically qualified to do an exam or any medical decision making is a provider. And counseling only does not include an exam or any decision making.
The requirements for a 99211 are incredibly broad. In fact, there are no specific requirements. Anything the patient comes in for that does not require the presence of the physician can be a 99211. Blood pressure checks, ear lavages, EKGs, vaccinations, that sort of thing.
However, the office does deserve to be reimbursed for any time spent counseling. For pediatricians, there is a code that includes the administration of vaccines and the time spent counseling the patient/guardian. You would use code 90460 for the first vaccine and 90461 for any subsequent vaccines. These codes are also nice because they do not specify the method of administration. You can use 90460 and 90461 for vaccines administered intramuscularly, nasally, or orally.
If the vaccine is administered with no counseling, you would use the regular 90471 and 90472 codes for your intramuscular administrations.
As an additional consideration, the 99212 gets paid a very small amount anyway. Probably less than $35.00. AND a copay gets applied that you’ll most likely end up waiving anyway. Getting your provider paid for at least the 90460 and one 90461 will be a higher reimbursement than billing with an incorrect code. And it is my job to make sure that I get my providers the highest reimbursement possible.
As always, if you have any questions or any clarifications, send me an email at firstname.lastname@example.org.