Otolaryngology Coding Alert

Medicare now allows same-day E/M service and allergy injection -- and your payers should, too

Before you write off another E/M service-allergy shot bundle, try these specialty-society-backed tactics.

Case study: One coder requested help for claims involving 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) and 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or CPT 95117 (... two or more injections). Insurance companies are denying the office visit as incidental to the immunotherapy injection, says Tonya Beans, medical biller for Lloyd Charles Jr., MD, in Upper Marlboro, Md.

Would a modifier be appropriate in these instances? Here's what allergy coding experts recommend.

Step 1: Get Official Modifier Guidance

When you report an office visit (OV) and same-day injection, CPT does not require you to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Medicare allows an office visit (OV) and injection on the same day without modifier 25.

Example: An allergist sees a patient due to nasal congestion (478.19), and then the patient receives her scheduled bimonthly series of two allergy injections for allergic rhinitis due to pollen (477.0). The physician performs and documents a level-two E/M service. You may report 99212 and 95117, according to Medicare rules.

Step 2: Update Payer on Policy Change

Billing 99212 or any other E/M service with 95115 or 95117 is a recent turn of events. Prior to Jan. 1, 2006, Medicare designated allergy injections as global-period codes, says Robert A. Nathan, MD, president of the Joint Council of Allergy, Asthma and Immunology (JCAAI), in a members- letter. The designation meant you could not bill 95115 and 95117 with an E/M service without using modifier 25.

New way: Under new Medicare policy, 95115 and 95117 no longer have global periods. Therefore, -you are allowed to bill an E/M service (including 99211, Office or other outpatient visit for the evaluation and management of a patient, that may not require the presence of a physician -) with allergy injection codes without meeting the requirements for modifier 25,- the JCAAI letter says. Because 95115 and 95117 include no payment for physician work, payment of a separate E/M service is appropriate. 

Problem: Some commercial carriers haven't gotten the message, says Kathy Anderson, CPC, practice consultant at Allergy Partners PA in Asheville, N.C. In fact, a survey conducted by JCAAI indicates practices across the United States are all having the same issues.

Step 3: Opt for 25 When Appropriate

Although Medicare policy and CPT guidelines do not require modifier 25 on claims for higher-level E/M services and allergy injections, payers may have system edits in place that make using the modifier necessary. -We usually add modifier 25 to the E/M and have no problems getting paid,- Anderson says.

Rest easy: The allergy specialty society backs resorting to modifier 25 in these situations. If you think an encounter meets the criteria for modifier 25 (for instance, the physician has provided a separately identifiable service distinct from the injection), consider resubmitting rejected claims with modifier 25, the JCAAI says.

Example: Higher-level office visits not related to the injection administration would probably qualify for modifier 25, the council says. But -make sure you have appropriate documentation.-

Step 4: Avoid Modifier on Related 99211

You can even report a minimal E/M service related to immunotherapy. Providers may bill for a nurse-only 99211 when dealing with clinical issues surrounding allergy injection administration, the JCAAI says. The service could represent directing a nurse who gives injections on what to do if a patient:

- was ill
- missed an injection
- had a large, local reaction or mild unreported systemic symptoms after his last injection.

Be careful: On claims involving a nurse visit related to allergy immunotherapy, don't append modifier 25 to 99211. When you bill 99211 for providing clinical advice related to the injection, modifier 25 is unnecessary and does not apply, the JCAAI says. But the nurse must document the medically necessary E/M service that she provided.

Step 5: Resubmit, Appeal, Educate

If commercial payers reject claims for E/M services billed on the same day as an injection, resubmit with 25 when appropriate, appeal if still denied--and inform the insurer of the 2006 policy change. Get started with the appeals letters below.

Last step: Complain. JCAAI wants you to notify the council if commercial payers or Medicare rejects claims for an E/M service on the same day as an injection. They will use this information to inform payers and Medicare carriers of the 2006 policy change. Identify the payers (such as carrier name) and the geographic area. Describe your appeals- activity and status including pertinent evaluation of benefits. Fax the information to (847) 934-1820 or e-mail it to info@jcaai.org.