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Therapeutic injection and Immunization admin

swallace1

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Local Chapter Officer
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12
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Nashville, TN
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Here is latest from a Healthcare plan in TN. Perhaps I am not seeming something, the healthplan is. Patient was seen for office visit, and as part of the visit received a flu shot as well as a therapeutic injection of Depo Medrol for another diagnosis.
Billed the following 99213 w/ modifier 25 for office visit, 90471 and 90658 for the flu shot, and 90772 and J1040 for the Depo shot.
The healthplan denied 90772 citing AMA/CPT guidelines, stating that the administration code was bundled with the 90471 code. Shots were given in different locations. I am inclined to appeal, however, I want to make sure I have not overlooked something.
The only reference I saw in CPT was that the admin codes were excluded under each other. I would like to appeal this case and make the healthplan accountable to the reference they cite.
Any other coding professionals have this come up? Am I on the right tract?
Thanks in advance.
 

bhaskins1

Networker
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92
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I would appeal. I have seen them bundle 90772 with an office visit if you don't attach Mod 25 but I don't believe they are correct in bundling 90772 with a vaccine administration. J1040 is a drug, not a vaccine so 90471 could not be used to report the administration. Just out of curiosity, what diagnosis codes were used?
 

Kris Cuddy

Guru
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205
Location
East Lansing, MI
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As long as the modifier 25 for the E/M services is supported by the provider's documentation, it will be necessary to add modifier 59 to the 90772.

The rationale is that there are two separate injections for two separate purposes, and it may be they were also in two separate locations.

Perhaps the carrier can add modifier 59 for you and reprocess, or submit a corrected claim to them?

Kris
 

pamtienter

Expert
NAB Member
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349
Location
Mound, MN
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You shouldn't need the 59 modifier on anything since there aren't any CCI edits between these codes, though sometimes payers have their own rules. I would appeal also.
 

bhaskins1

Networker
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92
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As long as the modifier 25 for the E/M services is supported by the provider's documentation, it will be necessary to add modifier 59 to the 90772.

The rationale is that there are two separate injections for two separate purposes, and it may be they were also in two separate locations.

Perhaps the carrier can add modifier 59 for you and reprocess, or submit a corrected claim to them?

Kris
Wow... Modifier 59 would not have occured to me... the hoops we have to jump through to get something paid. You may want to make a phone call before writing a letter... sometimes carriers will accept a verbal appeal/request for review.
 
Last edited:

Kris Cuddy

Guru
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205
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East Lansing, MI
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Interestingly enough, CMS allows only one initial administration per day. As the immunization administration 90471 is the "initial" injection administration, it falls to the provider to indicate the therapeutic was separately performed and separately reportable.

Remember, we are not sending the claims to intelligent persons who are able to understand on seeing the claim that these are definitely two separate services. But, we are sending the claims to computerized electronic processing where edits are in place in attempt to not overpay a claim.

With that in mind, it truly falls to us to tell the carrier's edit system; don't stop this claim and deny this line, this was a separate service we deserve reimbursement for. Hence, in this position, the only appropriate modifier would be modifier 59.

Hope this helps.

Kris
 

bhaskins1

Networker
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Interestingly enough, CMS allows only one initial administration per day. As the immunization administration 90471 is the "initial" injection administration, it falls to the provider to indicate the therapeutic was separately performed and separately reportable.

Remember, we are not sending the claims to intelligent persons who are able to understand on seeing the claim that these are definitely two separate services. But, we are sending the claims to computerized electronic processing where edits are in place in attempt to not overpay a claim.

With that in mind, it truly falls to us to tell the carrier's edit system; don't stop this claim and deny this line, this was a separate service we deserve reimbursement for. Hence, in this position, the only appropriate modifier would be modifier 59.

Hope this helps.

Kris

Well put... when you put it that way it makes sense... Again with the hoops! :D
 
Messages
5
Location
Dallas Texas
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With 5+ years experience billing for physician's, I have seen many ways to bill injection admin codes. I agree with adding the 59 mod to the 90772. This was a separate procedure than the flu shot. Although the edits prove otherwise, the insurance company may have their own guidelines. I would call and ask the rep if you can appeal w/ a 59 mod...if it would be reimbursed.

Treacie Hunter, CPC :)
 

pamtienter

Expert
NAB Member
Messages
349
Location
Mound, MN
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I worked for a large payer for years and learned a lot about the "dark side" (as the physicians I left called it). It's just as Kris said, edits are put in place (maybe just a bit tighter than they should be according to coding rules) but it's because that is the only way the automated claims processing program is going to read and process the claim the way they want it to. Keeps us on our toes with all the payers we have to deal with and their different systems but I just heard hula hooping is the newest exercise craze! :)
 

cdeveau

Guest
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5
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Help

Our billing company keeps rejecting 90772. We are billing 90772 Therapeutic inj. with J3420. They state 90772 is no longer valid. What other code is there for administration of B12 injection?:confused: :confused:
Thanks for your help.
 
Messages
4,466
Location
Milwaukee WI
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What's your place of service?

2008 CPT Professional Edition, page 383 ... under the guidelines for Hydration, Therapeutic, Prophylactic and Diagnostic Injections and Infusions: "... These codes are not intended to be reported by the physician in the facility setting."

Our clinics are all hospital clinics (POS 22), so we can no longer bill these codes, even when the physician him/herself is performing the injection.

F Tessa Bartels, CPC, CPC-E/M
 

Kris Cuddy

Guru
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205
Location
East Lansing, MI
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Not only at what place of service is the B12 injection being administered, yet also what other services are being billed with the J3420 and 90772?


Of course for 2009, we'll have to use 96372 and not 90772.
 
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