I am a little confused on this, as well. It does seem as though we need to add a modifer (25, i believe) to the E/M code when done at the same visit as vaccines. Of course, this means that there must be the seperately identifiable E/M service done. If the pt comes in JUST for the vaccines, I don't think we can bill the office visit. My biggest question is whether we are supposed to add the modifier when the pt comes in for a preventive visit (annual, well child, etc) and also has vaccines???
2013 guidelines are really specific for vaccine administration codes - they are to be reported in addition to a significant/separately identifiable E/M code (including both office visit codes and preventive medicine services - it even lists the code ranges). CPT guidelines are really specific when they want you to use a 25 modifier - the guideline would have said to use it, if it was meant to be used.
Preventive medicine guidelines also repeat the instruction to report vaccine administrations separately - again, with no modifier required. They do, however, specify that a 25 modifier is needed on an office visit, if it's billed in conjunction with a preventive E/M. And, if you're billing a regular injection administration (96372) with either an office or preventive E/M (or both), you'll need to add a 25 modifier to whatever E/M('s) you bill with it.
That being said - some commercial payers require you to add 25 modifiers in unnecessary situations (like when you're billing vaccine admins with office visit codes). Since there are some grey areas in the guidelines, and they don't explicitly say NOT to use a 25 modifier, technically, they can get away with doing that. Most don't go as far as to require a modifier on a preventive E/M with vaccines (but f they do, I'd definitely fight it, since there are 2 separate guidelines to reference).
If you're feeling especially argumentative, you can try to appeal their decision to require it on the regular E/M services, too - the guidelines do support billing without it. It will require a well-written appeal, that will probably have to go to a 2nd level appeal, if not further, to have any chance of paying - but it's worth the effort if you can get an entire payment policy overturned (which
can be done). You'll have more leverage to support your argument, if there's not a written policy specifying the use of 25 modifiers with E/M's billed with vaccine services; but don't let a written policy deter you, if there is one - just make sure to reference it in your appeal (and point out how the rationale isn't supported by CPT guidelines), so they don't waste time citing it, in another denial.
One last FYI: a lot of payers have a pseudo-automated appeal review, for the 1st level appeal. They really just verify that they meant to process the claim the way that they did (and that the denial isn't just a computer glitch), so your appeal may not actually be reviewed for its merit, before it's denied. I always recommend sending a 2nd level appeal, requesting a response that specifically addresses why your appeal has been denied, before giving up. If your 2nd level appeal denies, call to confirm that it was manually reviewed, and ask if the adjuster left any notes, explaining more about their decision, than the explanation on the EOB. (Of course, some providers would rather just tack on the 25 modifier, and be done with it, and that's okay, too - it won't hurt anything being on there, if they'd rather not fight it).
Hope that helps!
