CPT 96372 ONLY: Invega Sustenna Injection Visit

[christinaroseferrone@gmail.com]

Hello Everyone and Good Day,

Our local Medicaid denied CPT 96372 with the response that a modifier is needed. The member was seen only for their Invega Sustenna injection, so there was no E/M visit code where modifier -25 could be utilized. I have been racking my brain trying to figure out which modifier they are referring to. Unfortunately when I called Medicaid, they do not have the specific modifier listed to advise me as to which one to use. The Agent said the NDC nor the HCPCS code is required, just the modifier. Help! Can someone point me in the direction to the correct modifier for a single injection only visit by a Physicians Assistant? Thank you!

 

[SharonCollachi]

There is a distinct possibility that the denial reason and the agent are wrong. The agent was telling you their computer shows a modifier is needed. Doesn't mean that is correct; it just means that is what was on their screen.

I would bill the medication with a zero dollar (or a penny) if the patient supplied the medication. It certainly can't hurt, and it may be the answer. If this was commercial insurance, I would say that is DEFINITELY the problem.

 

[trarut]

I agree with Sharon. Another thought - does your Medicaid program require a modifier for other PA performed services?