E/M with injection - Medicare patients

smwermter

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I code for several family practice clinics and I was just told by the billing office that I can not code/bill the 90772 injection code with an E/M level on Medicare patients. They are saying that Medicare pays on the injection and not the office call and so I should not coded the 90772...just the E/M and the drug injected. Does that sound right to the rest of you out there? I was coding the E/M with 25 modifier, 90772 and the drug injected. I know that when I help out with ED coding that is the way it is done...so I am wondering if it is just different in the clinic setting. :confused:

Thanks in advance for the help! :)

Shelly Haataja, CPC
 

ARCPC9491

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90772 is not billable with 99211 for medicare. if a seperate E/M was performed significant of the therapeutic injection, you can code the E/M with modifier 25. you can charge the medicine too.

example:
99214-25 (documentation must always substantiate use of E/M)
90772
J Code

if you bill...
99211
90772
J Code

They will bundle 99211, pay 90772 and normally pay the J Code as long as your diagnoses are correct according to the NCD's/LCD's

With the commercial insurances, it can vary from payer to payer ...
 
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smwermter

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Thanks for your responce AR! Your first example is what I am talking about. The patient comes in for several complaints, it does warrent the 99214 and then they have their B12 injection. So, I am coding the 99214-25, 90772 and the J code. The billing staff is telling me that Medicare is only paying on the 90772 in that instance. That just doesn't make sense to me??? Any more thoughts? I think we are right in our scenerio and that they must be confusing that with the 2nd example you gave.
 

ARCPC9491

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Are you sure they are using modifier 25 on the E/M code?

According to the CCI edits, the two codes are payable with a modifier.

Did they call Medicare?

I would appeal with records if Medicare is giving you a hard time. But it could be the billing staff?

And if they aren't paying the J3420 (which is a big .10 cents!!) I bet you it's because the diagnoses are incorrect. Here's my LCD for Trailblazer's ... I'm sure yours is the same or comparable ... it was revised again on 10/01/08. and if so, the denial would kick back 'not medically necessary'

Medicare is establishing the following dual diagnosis limited coverage for HCPCS code J3420:
As a reminder, J3420 administered for anemia in the treatment of cancer requires the most recent HCT and/or Hgb reading on the claim. This applies to claims received on or after April 7, 2008, with dates of service on or after January 1, 2008.

Covered for:

266.2*
Cyanocobalmin deficiency

281.0*–281.1*
Other deficiency anemias


Note: Codes 266.2* and 281.1* as the primary diagnosis requires a secondary (dual) diagnosis from the table below.

281.3*
Other specified megaloblastic anemias, not elsewhere classified (combined folate- B12 deficiency anemia)


Note: No secondary diagnosis is required for 281.0*, 281.3* or V58.11*.

V58.11*
Encounter for antineoplastic chemotherapy


Note: Use code V58.11* when administering vitamin B12 as a part of a regimen that includes pemetrexed (J9305).




The following are secondary (dual) diagnoses to be used with 266.2* and 281.1* (primary diagnosis) to meet limited coverage for HCPCS code J3420:


336.2
Subacute combined degeneration of spinal cord in diseases classified elsewhere

357.4
Polyneuropathy in diseases classified elsewhere

564.2
Postgastric surgery syndromes

579.0–579.2
Intestinal malabsorption

579.8
Other specified intestinal malabsorption

V45.3
Intestinal bypass status
 
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smwermter

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I think that they just have been taking my 25 off and not submitting the injection code because they thought it was the same as the 99211 scenerio...and that I was unbundling. I have a call into the billing manager regarding this and that I feel it is being coded correctly and my reasoning. So, hopefully I will be able to get this confusion resolved. Thank you so much for your help and making me not feel like I am losing my mind!! ;)
 

smwermter

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Yes, I did and thank you. I'm not sure what is going on, I am pretty sure my dx codes that I am using aren't the problem. The response that I am getting from billing is "that just the way it has always been" and that "is what I was told when I started here". So, they are doing some investigating on there end and I'll see what they find out. I opened a can of worms for them that's for sure!! But, if they are billing it wrong or if it is being denied and shouldn't be either way we need to find the answer to the problem. Thanks you SO MUCH for all of your help and knowlege!! I appreciate it. :)
 

byronious

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I am trying to get a 99213 with 25 mod. a 96372 and j3420. Is this scenario one that medicare allows? the dx codes include 281.1, 533.90, 715.09
 
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