Unbundled codes

duppong

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One of our payers (Medicare advantage plan) is telling us that E/M codes are an unbundled code to 96372 (administration of injection) and are paying for the 96372 and not the E/M. This is the only payers telling us this all other payers have been paying. Just wondering if anyone else is having this problem and I have tried to find a resource to verify this but haven't been able to find anything. Any help you could offer would be greatly appreciated. Thanks!
 

sjsantjer

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96372

Our Medicare carrier will not pay for an E&M with code 96372. This is the example and rationale that they gave. Hope this helps.

Q. Could a significant and separately identifiable Evaluation & Management (E&M) be billed if a patient presents with a cough and fever, then the doctor examines the patient and orders labs and x-rays, patient is diagnosed with pneumonia and a shot of Rocephin is ordered? If all elements of a level 99213 are documented by the doctor, would we be able to charge a 99213 with the 25 modifier and 96372/J0696 for this visit with diagnoses code of 486? We are uncertain what “significant and separately identifiable” entails since the injection administration is a result of his decision making.

A. In the IOM, Medicare Claims Processing Manual, Publication 100-04, Chapter 17, Section 20.5.7, states “injection services… included in the MPFS are not paid for separately if the physician is paid for any other fee schedule service furnished at the same time.” Therefore, you would be able to successfully bill the 99213 for the E&M, and the J0696 code for the drug.
 

escorcia16

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I billed to AARP United Health Care 99215-25, 20610, J1020, J1885, 96372 but, 96372 was denied. It said it is an unbundled code. How can i fix it to get it paid?
 
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mitchellde

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Our Medicare carrier will not pay for an E&M with code 96372. This is the example and rationale that they gave. Hope this helps.

Q. Could a significant and separately identifiable Evaluation & Management (E&M) be billed if a patient presents with a cough and fever, then the doctor examines the patient and orders labs and x-rays, patient is diagnosed with pneumonia and a shot of Rocephin is ordered? If all elements of a level 99213 are documented by the doctor, would we be able to charge a 99213 with the 25 modifier and 96372/J0696 for this visit with diagnoses code of 486? We are uncertain what “significant and separately identifiable” entails since the injection administration is a result of his decision making.

A. In the IOM, Medicare Claims Processing Manual, Publication 100-04, Chapter 17, Section 20.5.7, states “injection services… included in the MPFS are not paid for separately if the physician is paid for any other fee schedule service furnished at the same time.” Therefore, you would be able to successfully bill the 99213 for the E&M, and the J0696 code for the drug.
What year did this appear in the manual? I ask because in 2004 Medicare issued a revision to the manual with regard to billing an E&M with an injection and stated that is a significant and separate evaluation was performed that it is appropriate to append the 25 modifier, and they instructed that they would accept rebilled claims at that time going back a year to correct this problem. I am sorry that I no longer have this link it is on an old computer that no longer functions :)
 

Aubrey

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We do not bill injections with E/Ms

I work in an OB office. We bill a lot of Medicaid and some Medicare. We as a rule do not bill medication injections if we bill an E/M too. We bill vaccination injections, but not other medications. The only way we would bill a medication injection is if it is done with a nurse as a walk-in, and the patient does not have an E/M on the same day. I just had to write off a Medicaid injection billed with an E/M; their edits prevent payment.
 
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