Add 99211 to Prolia only visit

hsmith67

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Currently I'm billing a 96372 along with the Prolia J Code. The plan of care had already been determined, Prolia shots, etc. Office manager feels there should be more profitability in the "visit" than the 96372 and the thin margin on the Prolia. Office manager thinks nursing should start checking/documenting a BP and use that to bill a 99211 in addition.

Thoughts?

Thanks for input,
Hunter Smith, CPC
 

Orthocoderpgu

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CMS (Medicare) has stated basically that "Medical necessity" is the "over-arching" criterion for payment as well as the criteria for the CPT code. Performing unnecessary work just to get paid a bit more is waste. My guess is that 95% of patient's getting Prolia shots are on Medicare. As a coder you should be aware of the penalties that Medicare has for fraud/waste & abuse. Your office manager is probably not certified (but I think should be) and does not know what they are really asking and the penalties that they will pay in the future. I would not even start to go down this road.
 

csperoni

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While I totally agree with Ortho here, I suggest another avenue. 99211 is a CCI column 2 edit with 96372. Even if you decided to provide unnecessary services and bill for them, you wouldn't get paid. If the office manager does not understand coding, they may understand not getting any additional money anyway.
 

thomas7331

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I agree with the other posts. You won't get paid for the 99211 as it's bundled to 96372 under Medicare and most commercial payer reimbursement policies and generally can't be bypassed by a modifier. Even if you do have a payer that will allow it, you can't support it just by having the nurse check a blood pressure - a 99211 requires an E/M service that has been ordered by the physician for a specific purpose. Also, the modifier 25 would need to be supported as well to show that this service was unrelated to the injection.
 

hsmith67

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CMS (Medicare) has stated basically that "Medical necessity" is the "over-arching" criterion for payment as well as the criteria for the CPT code. Performing unnecessary work just to get paid a bit more is waste. My guess is that 95% of patient's getting Prolia shots are on Medicare. As a coder you should be aware of the penalties that Medicare has for fraud/waste & abuse. Your office manager is probably not certified (but I think should be) and does not know what they are really asking and the penalties that they will pay in the future. I would not even start to go down this road.
Thanks! I agree and knew this already. I was trying to get my client to understand the seriousness of what she was asking of me. You are correct, she is not certified, in fact, she's 6 months into the medical field and has a lot to learn. Interestingly I gave the exact same quote to my client about "Medical necessity is the over-arching criteria..." I appreciate your response.
Hunter Smith, CPC
 

hsmith67

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While I totally agree with Ortho here, I suggest another avenue. 99211 is a CCI column 2 edit with 96372. Even if you decided to provide unnecessary services and bill for them, you wouldn't get paid. If the office manager does not understand coding, they may understand not getting any additional money anyway.
Good point about the column 2 edit, I hadn't thought about it that way but I agree. My post was to show my client that I did know what I was talking about and your response helped my case. Thanks for your reply!
Hunter Smith, CPC
 

hsmith67

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I agree with the other posts. You won't get paid for the 99211 as it's bundled to 96372 under Medicare and most commercial payer reimbursement policies and generally can't be bypassed by a modifier. Even if you do have a payer that will allow it, you can't support it just by having the nurse check a blood pressure - a 99211 requires an E/M service that has been ordered by the physician for a specific purpose. Also, the modifier 25 would need to be supported as well to show that this service was unrelated to the injection.
Thomas, thanks for your reply. My post was to settle a disagreement and your post helped. I agree 100%.
Hunter Smith, CPC
 
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Florence, AL
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Currently I'm billing a 96372 along with the Prolia J Code. The plan of care had already been determined, Prolia shots, etc. Office manager feels there should be more profitability in the "visit" than the 96372 and the thin margin on the Prolia. Office manager thinks nursing should start checking/documenting a BP and use that to bill a 99211 in addition.

Thoughts?

Thanks for input,
Hunter Smith, CPC
I do not think insurance will pay for both. Because the medicine alone is expensive. I feel they will deny the claims.
 
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