Primary Care Coding Alert

Question: A patient receives a bimonthly allergy injection and testosterone shot. Originally, the insurer denied the 90782 claims and suggested that I attach modifier 25 to 90782 and modifier 59 to 95115. Even though I disagreed with using modifier 25, I followed the company's instructions. But now the payer is including 90782 as a component of 95115 and recommending billing 99211 to compensate the testosterone shot work. What is the proper coding and how should I proceed?


Ohio Subscriber

Answer: When a patient presents for an allergy injection and testosterone shot and the family physician provides no evaluation and management service, you should report the claim as:

CPT/HCPCS codes

- 95115--Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection

- 90782--Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular

- J1080--Injection, testosterone cypionate, 1 cc, 200 mg.

ICD-9 codes

- 477.8--Allergic rhinitis; due to other allergen

- 257.2--Testicular dysfunction; other testicular hypofunction.

You are correct that no modifier is technically necessary on claims containing allergen immunotherapy and testosterone injection. As you mention, modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is not appropriate in this situation. The encounter involves no E/M service, and you are supposed to attach modifier 25 to an E/M code (such as 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient -).

Similarly, 99211 doesn't describe the scenario. Staff provide no E/M service; the patient simply receives the two injections.
 
Best bet: Try attaching modifier 59 (Distinct procedural service) to 90782 and leave 95115 unmodified. Since the insurance company incorrectly considers 90782 a component of 95115, using modifier 59 in this manner indicates that 90782 is a distinct service from 95115.

Although the current National Correct Coding Initiative, version 11.3, does not make 90782 a component of 95115, the payer may be following an outdated edit. From Oct. 1, 2002, to Dec. 31, 2004, NCCI bundled these codes, making modifier 59 necessary on 90782.

Last stand: If modifier 59 does not solve your 90782 payment problems, try appealing with the health plan. Alternatively, you could encourage the physician to contact the health plan medical director to resolve the matter on a physician-to-physician level.