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Coding 96372 - Provider-based facility

  1. Unhappy Coding 96372 - Provider-based facility
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    I am being told that we cannot bill 96372 in a facility setting by BC/BS and have been overpaid. We are a Provider-based Indian Health Facility. Our Place of Service code is 06. Can someone help with this?

  2. Default Coding 96372 - Provider based facility
    Im really curious why they are denying this. I would have to know exactly what you are billing, diag, proc. etc.... What other cpt codes are you billing with it? What are you doing to code 96372?

  3. #3
    Location
    Columbia, MO
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    Are you billing for the physician, or the facility?

    Debra A. Mitchell, MSPH, CPC-H

  4. Default
    We are billing, for example, 99213, 96372 and injected material, whatever the J-code may be. I have billed these both with and without the -25 attached to the E/M code. These are for the physician's fees...not the facility fees. For example, patient comes in for strep, sees the doctor for exam, gets a penicillin shot.

  5. #5
    Location
    Columbia, MO
    Posts
    12,570
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    if you are in a facility setting, and using the facility nurses then you canot bill the injection code nor the J code as those belong to the facility.

    Debra A. Mitchell, MSPH, CPC-H

  6. Default Modifier 25 & 51 for PPO insurance
    In an office setting billing for the physician if the office visit is submitted with modifier 25, the administration of the injection with modifier 51 & the injectable med (J code) all will be paid. Modifier 51 is normally used for procedures but is accepted by commerical carriers for the administration charge. Although these charges will be paid has anyone seen anything in writing that states this practice is acceptable?


    Quote Originally Posted by rtrancher View Post
    We are billing, for example, 99213, 96372 and injected material, whatever the J-code may be. I have billed these both with and without the -25 attached to the E/M code. These are for the physician's fees...not the facility fees. For example, patient comes in for strep, sees the doctor for exam, gets a penicillin shot.

  7. Default
    Quote Originally Posted by coder12 View Post
    In an office setting billing for the physician if the office visit is submitted with modifier 25, the administration of the injection with modifier 51 & the injectable med (J code) all will be paid. Modifier 51 is normally used for procedures but is accepted by commerical carriers for the administration charge. Although these charges will be paid has anyone seen anything in writing that states this practice is acceptable?
    I billed to bc/bs with the 51 and they will not pay this way either they say it is incidental to the primary procedure...
    vicki CPC

  8. #8
    Location
    Columbia, MO
    Posts
    12,570
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    you do not need a 51 as there was only one procedure. You need only the 25 on the office visit which should not be a 99211. There is a transmittal from CMS which was issued in 06 regarding it is acceptable to code a 96372 with an OV and a 25 modifier.

    Debra A. Mitchell, MSPH, CPC-H

  9. #9
    Default 96372
    If a patient comes into the walk-in clinic for a migraine and receives 2 IM injections can you code 96372 x2? Thank you (facility coding)

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