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Old 03-25-2011, 05:27 PM
Bonnie Owen Bonnie Owen is offline
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Default ov with modifier 25 and injection

I was told by a fellow co worker that Medicare allows an office visit with modifier 25 attached when billing an injection of a drug ( example Kenalog for allergies/rash) to get the adm fee 96372 paid. I disagree. I say content of service and modifier 25 should not be used. I know Medicare now covers adm fee on vaccines with OV w/ or w/o mod 25 for the adm fee, but I have never heard of adm fee getting billed and paid for by Medicare with OV with other injections , not vaccines. I am not talking about trigger points or injections into hips/ knees. Drugs like depo medrol, Kenalog, tordol that go into the IM.

Last edited by Bonnie Owen; 03-25-2011 at 06:08 PM.
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Old 03-25-2011, 06:16 PM
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Originally Posted by Bonnie Owen View Post
I was told by a fellow co worker that Medicare allows an office visit with modifier 25 attached when billing an injection of a drug ( example Kenalog for allergies/rash) to get the adm fee 96372 paid. I disagree. I say content of service and modifier 25 should not be used. I know Medicare now covers adm fee on vaccines with OV w/ or w/o mod 25 for the adm fee, but I have never heard of adm fee getting billed and paid for by Medicare with OV.
If you have a separate, significantly identifiable E/M service, apart from simply administering an injection, is reportable with modifier 25. It doesn't even have to be for a different diagnosis than what led to the shot - if a patient comes in with a problem, and the doctor decides to treat the problem with a shot (like Kenalog, or Rocephin), you can bill the appropriate level of problem-oriented E/M service with a 25 modifier in addition to the therapeutic/prophylactic injection admin. You technically don't need a 25 modifier when billing preventive visits with vaccine/toxoid administrations. Medicare follows CPT guidelines, to my knowledge.
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Old 03-25-2011, 08:32 PM
eadun2000 eadun2000 is offline
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Quote:
Originally Posted by Bonnie Owen View Post
I was told by a fellow co worker that Medicare allows an office visit with modifier 25 attached when billing an injection of a drug ( example Kenalog for allergies/rash) to get the adm fee 96372 paid. I disagree. I say content of service and modifier 25 should not be used. I know Medicare now covers adm fee on vaccines with OV w/ or w/o mod 25 for the adm fee, but I have never heard of adm fee getting billed and paid for by Medicare with OV with other injections , not vaccines. I am not talking about trigger points or injections into hips/ knees. Drugs like depo medrol, Kenalog, tordol that go into the IM.
Wow. Of course if you have a separate identifiable evaluation and management, then you can use mod 25 for the 96372. Where are you getting that you cannot do that? A procedure was performed. It should be coded.
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Old 03-26-2011, 07:17 AM
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Absolutely. CMS released a transmittal on this back in 2004 that it was acceptable to use a 25 modifier on the office visit when billing a 96372 as long as the parameters of the 25 modifier had been met. If the patient is scheduled for an injection then no there can be no ov in addition as the injection was pre planned.
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Old 03-26-2011, 12:18 PM
Bonnie Owen Bonnie Owen is offline
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Most other insurance companies consider the drug adm fee content of service of the OV and will not pay seperately.
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Old 03-26-2011, 02:37 PM
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Most other insurance companies consider the drug adm fee content of service of the OV and will not pay seperately.
Really? Maybe you should check for a contracting issue, then - all of our payers cover both. I honestly can't think of a single one that won't pay both when they're billed properly.

If anything, the OV denies as bundled to the injection admin - and that's only when the 25 modifier is forgotten. There's absolutely no reason your injection admin should be denying, unless you're also billing for another procedure during the same visit, and forget to add a 59 modifier to 96372, or if you're only billing a 99211, in which case, no - you can't bill that OV with 96372.
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Old 03-26-2011, 11:05 PM
eadun2000 eadun2000 is offline
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Really? Maybe you should check for a contracting issue, then - all of our payers cover both. I honestly can't think of a single one that won't pay both when they're billed properly.

If anything, the OV denies as bundled to the injection admin - and that's only when the 25 modifier is forgotten. There's absolutely no reason your injection admin should be denying, unless you're also billing for another procedure during the same visit, and forget to add a 59 modifier to 96372, or if you're only billing a 99211, in which case, no - you can't bill that OV with 96372.
I agree with you 100%. If it is billed correctly, then it should be paid. I have NEVER had one denied/bundled when a modifier 25 was added and/or 59 if another procedure was done on that same visit. Scares me to think how much revenue is just "walking out the door". Wow!
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Old 03-27-2011, 09:57 AM
Bonnie Owen Bonnie Owen is offline
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Thank you, I have been misinformed.

Last edited by Bonnie Owen; 03-29-2011 at 05:12 PM. Reason: New information
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Old 03-29-2011, 05:14 PM
Bonnie Owen Bonnie Owen is offline
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Denial from BC today. OV w/ mod 25, 96372, and J code. 96372 denied inclusive to OV. No other procedures this day, thus no need for mod 59.
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Old 03-29-2011, 05:29 PM
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Denial from BC today. OV w/ mod 25, 96372, and J code. 96372 denied inclusive to OV. No other procedures this day, thus no need for mod 59.
What was the dx, the visit level and the drug?
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