Practice Management Alert

If the denials are unfounded, you should fight back

If your practice administers injections, you need to know when - and when not - to appeal a denial for an injection and a separate E/M service on the same day. Check out these real-life billing scenarios:
 
Problem #1: We've always billed for an E/M visit and a joint injection on the same day and gotten paid with no problems. Suddenly some of our carriers started saying they wouldn't pay for both codes on the same day.
 
Problem #2: Sometimes a patient comes into our office specifically for a B12 injection - and in those instances we report only 90782 for the injection and J3420 for the drug. However, other times a provider will render a separate E/M service first and then administer the B12 injection. These claims are denied every time.
 
Think about how you would solve these billing problems, then read the answer  below.

 
Solution: Knowing the details of how to bill for joint injections and B12 shots is the only way to avoid denials - or fight them once they occur.

Problem #1 - Joint injections

Many orthopedists have recently complained that payers have simply decided to stop paying for medically necessary E/M services on the same day as joint injections, such as knee joint injections.
 
Example: A patient visits a physician who diagnoses the patient's joint pain as arthritis. The physician then performs a joint injection, such as 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). If the physician performed a separately identifiable E/M when he examined the patient to determine the cause of the joint pain and the need for the injection, the physician should be able to bill for both the E/M and the injection, says consultant Ryan Price with Aviacode in Salt Lake City. 
 
Careful: If the patient is scheduled to come in for an injection in advance and there's no reason to perform a separate exam, you shouldn't bill for an E/M visit, says Mary Brown, a coder with OrthoWest in Omaha, Neb.
 
But if it's a new problem or if the established patient has new complaints, then there is medical necessity for the physician to perform an E/M service to determine the need for the injection - and bill for it. Still, "some companies won't pay for it no matter what," Brown says. She recommends appealing the denial regardless.

Problem #2 - B12 Injections

Most Medicare carriers accept 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for the B12 administration and J3420 (Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg) for the supply of the drug.
 
Downside: Nearly all Medicare and private carriers refuse to pay for the injection code if you report an E/M code, such as established patient code 99211, on the same day. This rule applies even if you attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M.
 
"I would not recommend reporting an E/M with a B12 shot," says Lisa Center, CPC, quality review coordinator for Freeman Health System in Joplin, Mo. Remember that code 90782 includes RVUs for the nurse's work administering the injection, so reporting 99211 in addition would be excessive.
 
Idea: If your physician performs a distinct E/M service that you deserve payment for, you may want to consider having the patient return for a separate visit to receive a B12 injection.