Revenue Cycle Insider

Remember to bill the correct number of units for each J code.

When a patient requires an injection during an office visit, it can be easy to miscode the encounter for a variety of reasons. Let’s review some common HCPCS injection codes, their uses, and how to correctly code them alongside evaluation and management (E/M) services.

Continue reading to improve your office visit and injection combination coding skills.

Ace Your Antibiotic Injections

Whether your office administers a few antibiotic injections a year or a few every week, it’s important to know how to code them correctly alongside an office visit. Take a look at a common antibiotic injection below to keep your coding sharp:

• J0696 (Injection, ceftriaxone sodium, per 250 mg): This code is used for a Rocephin injection, which is an antibiotic used to treat many kinds of bacterial infections, including severe or life-threatening forms such as meningitis.

Make note: For each of the HCPCS codes covered, you will need to bill for the correct number of units used based on the provider’s notes.

You will also need to add a drug administration code to your claim for these injections, depending on your practitioner’s method; your choices are 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) or 96374 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug).

You will then choose an appropriate E/M code from the 99202-99215 (Office or other outpatient visit …) code set for your claim.

Lastly, you will need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to show that the injection and the E/M were significant, separate services.

Look to These Codes for Anti-Inflammatory Injections

Injections to alleviate inflammation and immune disorders are necessary when more conservative therapies aren’t bringing a patient the relief they need. Let’s review a few commonplace injections for these symptoms that can be performed in the office:

• J3301(Injection, triamcinolone acetonide, not otherwise specified, 10 mg): This code is used for a Kenalog injection, which is a corticosteroid used to reduce inflammation and treat a variety of conditions such as allergic disorders, skin conditions, ulcerative colitis, arthritis, lupus, psoriasis, or breathing disorders.
• J1010 (Injection, methylprednisolone acetate, 1 mg): This code is used for a Depo-Medrol injection, which is a corticosteroid used to treat inflammation and immune system disorders.
• J1885 (Injection, ketorolac, tromethamine, per 15 mg): This code is used for a Toradol injection, which is a nonsteroidal anti-inflammatory drug (NSAID) used for short-term treatment of moderate to severe pain.

Become an Expert at Vitamin Injections

Vitamin injections are normally administered when a patient’s deficiency is causing a health concern or condition such as anemia or skin bruising. Here are the codes you’ll use for vitamin injections:

• J3420 (Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg): This code is used for a vitamin B12 injection, which is used to treat or prevent vitamin B12 deficiency and certain conditions, such as pernicious anemia, that are related to vitamin B12 deficiency.
• J3430 (Injection, phytonadione (vitamin K), per 1 mg): This injection is often administered to treat or prevent vitamin K deficiency, which can lead to problems with blood clotting and bruising.

Test Your Skills With This Example

Scenario: An established 72-year-old patient presents with a three-month history of easy bruising and bleeding. After performing a brief history and exam, the provider administers an injection of 90 mg phytonadione to immediately increase the patient’s vitamin K levels and help decrease bruising and improve blood clotting. The patient is then sent home with instructions to fill a prescription for the same drug in pill form. The patient will follow up in eight weeks with the practitioner.

On your claim, you should report:

• J3430 x 90 for the phytonadione injection (You will need to bill for 90 units as J3430 is coded as 1 mg each, but the provider injected 90 mg.)
• 96372 for the administration of the injection
• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.) for the office visit
• Modifier 25 appended to the E/M code to show that the injection and the E/M were significant, separately identifiable services
• R23.3 (Spontaneous ecchymoses) appended to J3430 and the E/M code to represent the patient’s bruising condition.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC