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Coding Cues


Answers to your questions about...immunization codes; smoking counseling; new or established patients

Key Points

Vaccine administration

An adult patient came in to have some vaccines administered that he didn't get during his annual exam. My nurse gave him the injections. Can I submit 99211 for the nurse visit?

No. You shouldn't use 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician . . .) if there's a CPT code that more accurately describes the service. In this case, you'd use the immunization administration codes-90471 for the first immunization and 90472 for each additional one. Don't forget to also report the actual vaccine products.

During their office visits, I talk to patients about quitting smoking. A colleague told me that Medicare covers visits for smoking cessation counseling. I'm sure there must be rules-what are they?

Medicare will pay for two face-to-face counseling attempts a year, and each of these attempts can include up to four sessions. So that means that you can counsel a patient for a total of eight sessions in a 12-month period. If the patient needs more sessions, he can get another eight sessions after 11 full months have passed since his first Medicare-covered session. For example, if the first session was in June 2007, his second series of eight sessions can start in June 2008.

If each of the sessions lasts three to 10 minutes, you should submit the claim with G0375 (smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes). Sessions that last more than 10 minutes should be reported with G0376 ( . . . intensive, greater than 10 minutes). Remember that any counseling you do that lasts less than three minutes is included in an E&M visit, and you can't bill the counseling separately.

The diagnosis codes you use should indicate the disease or adverse health effect that's related to tobacco use, or a condition that calls for a drug that interacts adversely with tobacco. For instance, say you spend 15 minutes in a session counseling a patient who smokes and has emphysema. Report G0376 along with 492.8 (emphysema, lung or pulmonary, not otherwise specified) and 305.1 (tobacco use disorder).

Be sure that your documentation supports the time as well as the details of the counseling session. And before submitting your claims, always ask your private payers what their policies are on reimbursing smoking cessation counseling.

New or established?

I joined a new group in a neighboring town, and a patient I'd treated a year ago at my previous practice came to see me. Do I consider her to be a new or an established patient?

She's established. According to the CPT definition, "an established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." Even though you're new to this group, you've seen the patient and provided professional services to her within the previous three years. And it doesn't matter if she transferred her medical records to your new office or how long you may have had those records. The amount of time that's passed since your last encounter with her is the deciding factor.

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health