Primary Care Coding Alert

Version 11.3 fills CPT void on 90788's modifier 25 role

New guidelines confirm that you need modifier 25 when reporting an office visit with a therapeutic or antibiotic injection.

The National Correct Coding Initiative, version 11.3, effective Oct. 1, bundles office visit codes (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient -) with injection administration codes:

- 90788--Intramuscular injection of antibiotic (specify)

- G0351--Therapeutic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.
  
Bypass Most Bundles With Modifier 25

You may, however, break the E/M service-injection bundle with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). The edits allow a modifier to bypass all 99201-99215 and 90788/G0351 bundles, except for claims containing 99211 (... that may not require the presence of a physician ...).

The lowdown: This edit doesn't come as a big surprise to Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa. Many carriers already require modifier 25 when you report an office visit with a therapeutic or antibiotic injection.

Why: To charge 99201-99205 or 99212-99215 in addition to 90788 or G0351, the visit must be significant and separate from the injection administration. Payers often expect you to append modifier 25 to the E/M code to indicate the service's significant, separately identifiable nature, Falbo says. -The edits solidify this principle.-

Gain Guidance Where Little Existed

Some coders welcome the modifier clarification. -CPT's medicine section is very vague on using modifier 25,- says Carol Hall, CPC, coding/reimbursement specialist at California Family Health Council in San Diego.

While the Vaccine/Toxoids subsection offers modifier guidance, the AMA is silent on E/M service reporting with therapeutic or diagnostic infusions. -Significant, separately identifiable E/M services should also be reported,- states the AMA in the Vaccine/Toxoids subsection introductory notes. CPT's Therapeutic or Diagnostic Infusions (Excludes Chemotherapy) subsection notes do not address the topic. The new edits clarify that you need to use modifier 25 with 90788 claims involving an office visit.