Wiki Modifier 76 - getting asthma injections

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wverret

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Scenario

15 yr old male with chronic and severe asthma is seen in pediatrician's office on 8/23/12. Child has been getting asthma injections since 8/1/08. Child receives two injections of XOLAIR biweekly. Services are provided in ped's office, not an ASC or Hospital Surgical suite.

Clinic bills 99211-25 and 96372-76x2

I asked the clinic why the modifier 76 was used, and they responded that's what the allergist's office told them to how to bill. The clinic states that they give him two injections, one in each arm each visit

Now I've read the descriptions in both CPT and CPT Assistant and the book Coding with Modifiers. CPT mentions "procedures" and "services" performed by same physician. The info in the Coding with Modifiers book described procedures like femoral-popliteal bypass graft (35556).

Is this an appropriate use of modifier 76? inquiring minds want to know.

BTW, I'm an auditor with the Oregon Medicaid program and I do post-payment review.
Thanks
Willie
 
First the 99211 is not appropriate to be billed when the patient presents for a planned injection. Second then76 modifier is for a repeated service in a separate session on the same day. Two injections in the same office visit but different sites should get the 59 modified for separate procedure. The difference is huge in terms of reimbursement. The 76 will bypass multiple procedure discounting, and the 59 will allow for the discounting. When two procedures are performed in the same session then discounting is appropriate and should not be bypassed.
 
Hi Willie,

Perhaps the office is confused with what treatment the patient is receiving, I agree with Debra, injections do not get a 76....but inhalation treatments do, per CPT
 
Yes Missy inhalation treatments do because typically there is a physician assessment in between each treatment so technically each is performed in a separate session.
 
Allergy injections

I disagree. I would bill the 99211 that is appropriate for nurse visits like preparing and administrating the drug. The 25 modifier is required. The injections only require the moodier 50 L on one and Modifier 50 R on the second. You are only saying it was given bilateral. No further explanation is needed the 50 clearly explains the services.
59 and 76 are for surgical and diagnostic procedures things that are not normally done more than once in a day.
 
jorzano55@gmail.com said:
I disagree. I would bill the 99211 that is appropriate for nurse visits like preparing and administrating the drug. The 25 modifier is required. The injections only require the moodier 50 L on one and Modifier 50 R on the second. You are only saying it was given bilateral. No further explanation is needed the 50 clearly explains the services.
59 and 76 are for surgical and diagnostic procedures things that are not normally done more than once in a day.
Click to expand...

The 99211 is not appropriate for injections as the code for injection administration covers all the nurse activity. The 25 modifier says that the visit level is being billed for activity that is over above and beyond that of the procedure. When a patient presents for a planned injection, there is no activity beyond what is req united for the injection, therefore no visit level can be justified or billed. The 50 modifier is not appropriate as injection admin is not a bilateral service, and when you use the 50 modifier you do not also use the art and Lt and you list only one line item with a 50. 59 and 76 are not restricted to surgical services.
 
Xolair injection billed with E/M

I do post payment review for medicaid and I have an instance where the provider is billing 99213-25 along with 96372 fir the Xolair injection. The injection is the reason for the visit. The NP does see the patient and writes a note. Am I correct that the E/M can't be billed in this circumstance unless more is substantiated? Thank You.
 
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