Modifer 25 and Injections


Austin, IN
Best answers
I have a question regarding Modifer 25. There is a big arguement going on whitin our office. The billing department is billing something incorrectly after we have already coded it .

We feel that E/M codes with 90772 or 90741 need a 25 modifier. The director of the business office is stating we do NOT need a modifier because a company called BLUE Company told us that. I disagree completely. I feel we need a modifier 25 with this injections and E/Ms. Can someone please verify. I also looked at our coding magazine for November 2007 and it says yes use a modifier 25. Can anyone help me?

I don't see that 90772 and 90741 are listed as "E/M" codes in the cpt book. I see them under the "Medicine" section, which would prevent you from appending modifier -25 to them. As you know, modifier -25 is only for use with codes found in the "E/M" section of the cpt book.

I do know that if an "E/M" visit is billed in conjunction with these injection admin codes, then the "E/M" code gets the modifier -25. Keep in mind that CCI Edits bundles 90772 with some "E/M" codes (ex=99212-99214) and would also then require that you append a modifier -59 to injection admin code. The only exception to this would be if it is billed with a 99211 in which instance CCI Edits do not allow them to be billed together.

Hope this helps!
I am aware that Modifier 25 goes with the E/M Code , not the administration of the drug. My question is " when a patient comes for an office visit and the Dr decides to do an injection ( example code: 90772 or 90471 ) would we put a modifier 25 on the E/M code?"

Thanks for your input. I'll look into the -59
Modifier 25

Yes, you do use modifier 25 with the E/M code if an injection is given at the time of the office visit. We give Procrit injections in our office & if the patient is in to see the doctor & is due for a Procrit injection, we put modifier -25 with the E/M code. Hope this helps!!
Hi ValRider,

I misread your question....oops! I do see where you indicated that the
-25 modifier goes on the E/M....sorry about that!

I would say that if the reason for the visit and the reason for the injection are "significant and separately identifiable" (different conditions, symptoms), then yes I would use the -25. According to CPT description of the modifier, you don't even have to have different dx codes to use modifier 25 but it seems to help when appealing for denials.
I have been researching this very issue for the last three days, and yes, if the injection is something that was decided within the course of the visit, you do need to append the E/M with the modifier -25. If it is not appended, the services will be bundled and you will likely get payment only for the injection, not the E/M.
E/M and Procrit

If the reason for the visit is to adminster the procrit, then no E/M service can be billed even if the doctor sees the patient. The E/M (with modifier 25) would only be billed if there was a separate E/M service delivered at the time which is not related to the procrit, right?
It was the summer of 06 when CMS rlease a transmittal regarding office visits and injections. They had previously bundled these together and now as of the date of the bulliten reversed this decision and stated that if an injection was decided on in the course of the office encounter then you must append a 25 modifier to the office visit and list the injection admin code as well. You will find this in the transmittal section in 2006 on the CMS website.
Modifier 25

Would you use 25 modifier with a nurse visit of 99211 when a pt comes in for an injection or multiple injections..
If the only reason the patient is coming in is for the injection, bill the med and the administration code only.
You indicate that you think a 25 modifier needs to be applied to the E/M code. We don't charge for the administration injection codes when the patient also sees a provider on the same date. You would then only charge the E/M (no modifier needed) and injection(s).
You cannot bill the nurse visit 99211 with the therapeutic injection 90772 (which is actually 97632 for this year 2009) because this injection is given with direct physician supervision where as the nurse vist 99211 is stating without physician supervision. So I would not append a modifier 25 or report the nurse visit 99211 at all with this particular injection code.

Hope this helps...
That is correct, you do not report the 99211 to give an injection because the code is for the administration of the serum which includes all nursing management and supervision.