Eval/Injections

xzbgt7

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Hey everyone, I hope someone out there will be able to help me. I work for a family practice clinic. Will Medicare pay for a E/M, 99204, and also an injection, 20610 on the same day and not consider it global or discount the injection? I am being told Medicare will consider this global because the injection was decided upon during the E/M.

Thanks,
Layla
 

mitchellde

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if your E&M meets ther criteria of significant and separately identifiable then yes with a 25 modifier. Just remember ever procedure including injections has as a part of the procedure the assessment necessary to perform all components of the procedure. You do not need 2 different diagnosis code. And then yes they will pay for both.
 

andreljones

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E/m and injection

Since patient is new patient from the 99204 code you gave, you can bill it with a 25 or 57 modifier. However, I would bill the e/m code with dx for evaluation and the injection with dx for reason performing injection...and then Medicare will pay. If you bill with same dx and no modifier yes they will find it global. You may need to include notes.
 

ollielooya

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We have one carrier that states they abide by MCR guidelines yet WILL not pay unless two separate dx's are submitted to meet criteria for modifier 25. For this certain carrier we always have to appeal with chart notes and the CMS guidelines for use of modifier 25 (per the one dx) to receive payment for the EM visit. Otherwise, it is bundled OR injections will pay but not the EM.

---Suzanne E. Byrum CPC
 

mitchellde

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We have one carrier that states they abide by MCR guidelines yet WILL not pay unless two separate dx's are submitted to meet criteria for modifier 25. For this certain carrier we always have to appeal with chart notes and the CMS guidelines for use of modifier 25 (per the one dx) to receive payment for the EM visit. Otherwise, it is bundled OR injections will pay but not the EM.

---Suzanne E. Byrum CPC
I have not read any MCR guideline that states you need 2 diagnosis when using a 25 modifier. I bill with 1 often and never have an issue. Can you provide this policy/guideline please??
 

armen

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We have one carrier that states they abide by MCR guidelines yet WILL not pay unless two separate dx's are submitted to meet criteria for modifier 25. For this certain carrier we always have to appeal with chart notes and the CMS guidelines for use of modifier 25 (per the one dx) to receive payment for the EM visit. Otherwise, it is bundled OR injections will pay but not the EM.

---Suzanne E. Byrum CPC
I have never seen or heard anything like this. We have no problems with reimbursement and we use the same Dx for E/M and Inj. I would ask your payer to give you a copy of MCR guidelines. I would love to see it. Please see official MCR guidlines: http://www.cms.gov/mlnmattersarticles/downloads/MM5025.pdf

The Centers for Medicare & Medicaid Services (CMS) has clarified the documentation requirements and policy requirements for the use of CPT modifier -25 used with E/M services. Please refer to the manual attachment to CR5025, The Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.6, for revisions regarding the use of CPT modifier -25.

Physicians and qualified nonphysician practitioners (NPP) should use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period.

Common Procedural Terminology (CPT) modifier -25 identifies a significant, separately identifiable evaluation and management (E/M) service. It should be used when the E/M service is above and beyond the usual pre- and post-operative work of a procedure with a global fee period performed on the same day as the E/M service.

Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service with a global fee period. Modifier -25 is added to the E/M code on the claim.

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified NPP in the patient's medical record to support the need for Modifier -25 on the claim for these services, even though the documentation is not required to be submitted with the claim.

Your carrier will not retract payment for claims already paid or retroactively pay claims processed prior to the implementation of CR5025. But, they will adjust claims brought to their attention.

Carriers will not pay for an E/M service reported with a procedure having a global fee period unless CPT modifier -25 is appended to the E/M service to designate it as a significant and separately identifiable E/M service from the procedure.
 
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