Wiki Lupron Injection and an E/M


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Our practice recent underwent an extensive BCBS audit. Unfortunately, they seem to have thrown out all of the E/M codes, even when billed with a -25 modifier, when billed together with the Lupron and Testosterone injections. We are working with the billing department to see what we should appeal and what we should not. Our confusion is regarding what makes something "separate" enough to justify billing the E/M code.

For example, patients coming in for their Lupron injection are going to billed out as 185. So, when the physician just bills for the Lupron, that he discussed the PSA result and ordered the next one, we understand why they would throw out the E/M.

However, there are patients that the physician clearly documented a CC/HPI on another diagnosis, documented an exam, and had some degree of MDM regarding the other diagnosis (in one example it was microhematuria and another it was elevated PSA, despite having had radiation and being on Lupron). These were thrown out as well! But, these would seem to qualify as "separately identifiable"??

Has anyone else had any experience with this??