Wiki Modifier 25 or 59 - medicine practice


Best answers

We frequently bill patient office visits and injections in our internal medicine/family medicine practice. Lately, we have noticed injections being bundled or denied all together in scenarios like this:

99213-25 780.79, 401.9
96372 281.0
69210-59 380.4

Ins co. paid on everything except 96372, stating that it was bundled into the other procedure. How can an injection code be bundled into an ear irrigation? Is it because the ear irrigation is a procedure, therefore, any procedure would include an injection of a local anesthetic, if necessary? In this case, nothing is injected during an ear irrigation, so how would this be explained?

Hi PCallanan,

Can you tell me where I can find this information regarding 96372 being bundled into the office visit?

We bill injections and administration of injections with office visits with a modifer-25 all the time because we use a seperate diagnosis for the injection. They have always paid, but this time because the ear wash was on the claim as well, now they want to bundle the injection code.

For example, the following is how we routinely bill

Pt comes in for a follow-up appt to discuss lab results- Dx. 401.9, 272.2, 250.00. Also, the pt has a hx of b-12 defeciency and gets a monthly b-12 injection, so we bill as this:

99213-25 Dx codes. 401.9, 272.2, 250.00
96372 & J3420 Dx. 281.1

So please if you can find any source where I can read this information, please let me know.
When two separate services one ear irrigation and one intramuscular injection on the same day has been done, then we can bill for these two services separately provided 59 modifier is used along with IM injection code to indicate the payer that these are two distinct procedures and not a single procedure.

Here the two procedures are distinct and try using 59 modifier to the IM injection since this is the smallest procedure. Always use 59 modifier to the procedure with least payment. Hope it helps.

In some instances, carrier specific rules, 96372 is not reimbursable even with mod-25 on the office visit. For a long time, one of our BCBS HMOs would not reimburse it. Check with that particular insurance companies provider representative.