Wiki How to bill for injection w/ office visit

[lmeusch@northeasternhealth.org]

I am having issues with getting paid for injections with an office visit. Here is an example of a visit we were denied the office visit.
Patient came in for allergies.
CPT code 99213 with DX 477.9
CPT code J3301 with DX 477.9
CPT code 96372 with DX 477.9
We were denied the office visit, does anyone know how to bill this out correctly to get paid for the office visit as well as the medication?
Linda

 

[jamie@beneficialmb.com]

If there is just one diagnosis for the visit, the 96372 is included in the office visit. You would remove the 96372 and just bill the J code and office visit. Now if there were 2 or more diagnosis codes and the 96372 and J code were different than the primary diagnosis, then you could bill the 9921- with a -25 modifier and the 96372 and J code. Hope I didn't confuse you there.

 

[JesseL]

If patient came in for just the injection or scheduled injection, then bill only 96372. If the patient presented with a new problem that needed a thorough exam, prescriptions, etc and also got an injection, I would bill 99213-25 with 96372

 

[mitchellde]

You do not need a different diagnosis to use the 25 modifier with the visit level. You only need the documentation to support a significant encounter from the injection administration. You would never bill the E&M code and the Jcode for the drug only. If you cannot support a significant office encounter then you would bill the injection admin and the J code and not the E&M. If the drug is not a covered drug then the administration will not be covered either and it will be patient responsibility.

 

[CFINDLING]

You do not need a different diagnosis to use the 25 modifier with the visit level. You only need the documentation to support a significant encounter from the injection administration. You would never bill the E&M code and the Jcode for the drug only. If you cannot support a significant office encounter then you would bill the injection admin and the J code and not the E&M. If the drug is not a covered drug then the administration will not be covered either and it will be patient responsibility.

Debra-I do not work in our billing office nor do I code on a daily basis, I work in our EHR software administration and have been brought into discussions to see if the system could assist the billing office with various issues they have with payers/denials. One of the big ones is office visits with injection and immunization codes included. The billing office states that they are just appending the 25 modifier when it is absent because the payer is requiring it to pay the claim. I just want to make sure that we are not doing anything wrong in doing this. I have been reading many posts and articles around the office visit and 96372/9047x issues and debates, I have found your comments a few times and they are always consistent. But there are many discussions where no 2 coders or billers agree. Some say these are never paid separately from an Office visit with a modifier while others say you should add the modifier and should get paid. It is very confusing as to what the right thing to do is. What I think I am understanding you to say in this comment is that if a provider sees a patient for pain, illness, etc and performs a history, exam and decision making-assessment plan to decide to give an injection for the treatment of said illness/pain, etc then it is a significant and separate service and the 25 would be appropriate. I feel like in these cases the provider is providing work to support the modifier 25. Is that what I am understanding? Is there somewhere that you can point me in some clear guidance on this?