Wiki Immunizations at the same time as Prevent Med

[robertke]

We have an insurance company telling us that we have to put a 25 modifier on the prevent med codes 9938? - 9939? in order to get paid for the immunization administration code 90471-90472. They tell us that it is part of the CPT coding guidelines, page 369 of the professional edition. I have not seen it written stating that the 25 modifier is required on the prevent med code when the administration is being done for immunizations. Does anyone else have this senerio happen as this is how the insurance company interperts the guideline on page 369. They made this in effect starting March 15, 2007 only because the guideline states significant and separately identifiable service is why they are requiring the modifier on the prevent med code. Any input on this would be greatly appreciated as how you would interpert the guideline. Thank you for you time.

Kelly

 

[Susan]

Immunizations at the same time...

Kelly;
In reading the Guidelines on page 369 of the professional version of CPT I can understand where the carrier would interpret the guidelines as needing a modifier 25 for the E&M service provided the same day. I run into carriers telling me how to use, or what modifiers to use on a regular basis. I have even tried to tell them that the modifier is not necessary per coding edits. If you carrier is telling you to append the modifier to get paid properly then be sure you append the -25 modifier. Understanding guidelines can be easy at times, understanding the carrier's understanding of the guidelines can make us a bit crazy.

 

[sharonvalwa]

Hi,
Also keep in mind that a provider may tell you these things in order to avoid your claim to be denied due to a system limitation. The best thing you can do is document the date and name of the person at the insurance company that gve you this info and keep it for future reference.