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ov with modifier 25 and injection

  1. #21
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    Exam Training Packages
    Quote Originally Posted by Bonnie Owen View Post
    B12 did not deny, it's 96372 denying cos. Where are you located?
    Lubbock, Texas...You?

  2. #22
    Default Is it possible...
    Is it possible that the admin's being 'included' in the J-codes, instead of the E/M? That would make more sense to me. I'm not positive, but I think I've seen administration codes bundled into J-codes for Medicare before. It's something you should definitely look up on your MAC's website. I also believe that there are a few paragraphs in the back of the HCPCS books, but I don't have mine with me, so I'm not much help telling you where to look.

    If that's not the case, you should definitely appeal with records and documentation supporting the way you're billing it (according to CPT guidelines). That's not something that's done nationwide, and it contradicts CPT guidelines - when many patients rely on some kind of secondary commercial or Medicaid coverage, it's unreasonable to ask you to follow some made-up utilization of CPT codes and modifiers, just for them. I'd fight this one all the way to the state department of insurance (or insurance commisioner - whichever's relevant).
    Last edited by btadlock1; 04-23-2011 at 10:00 AM.

  3. Default HealthNet
    I was told that if the nurse uses a questionnaire, asks the patients about side effects, etc....we can charge the 99211 for Depo's, Progesterone Shots, Vaccines, etc...

    I always thought an E/M has already been in place and the patient is just coming in for a scheduled injection so we can only charge for the meds and inj fee 96372....

  4. #24
    Location
    Columbia, MO
    Posts
    12,571
    Default
    You are correct the nurses time involved in all aspects of the injection are included in the injection administration code.

    Debra A. Mitchell, MSPH, CPC-H

  5. #25
    Smile Modifer 25 fdoor 96372
    You can get you in trouble i would becareful. If you have a patient in for an acute issue only and they decide to give a kenalog injection etc.... this would be consider inclusive to the EM code the OIG watches very closely the use of all modifers...
    96372 with out an office visit but supervision of a physician is how i see this code being used or if patient comes in for two different issues. Most insurance companies will co97 this.



    Just my thoughts....
    Last edited by lseiter; 11-12-2012 at 07:46 AM.

  6. Default Medicare OV with injections
    I have "heard" that for 2013 Medicare has stated that an office visit and an injection (example knee injection for osteo w/Jcode meds) can not be billed in the same day.

    Is it true that if a patient needs an injection they have to schedule it seperately?

    Lost on this one! Jacque

  7. #27
    Wink confused too for 2013
    Pt can be seen for an office visit and injection on the same day. We do need to add a modifer 25, i believe to the E/M code when done at the same visit as vaccines or injections. Of course, this means that there must be the seperately identifiable E/M service done. If the pt comes in JUST for the vaccine or injection, we cannot 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??? Any help on this would be much appreciated!!
    Last edited by alosiewski; 02-15-2013 at 10:17 AM. Reason: Clarification of response

  8. #28
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    Quote Originally Posted by alosiewski View Post
    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!
    Last edited by btadlock1; 02-15-2013 at 10:34 AM.

  9. #29
    Default
    This is great info!! Coming from a very small facility, we just don't always have the manpower to work appeals the way it would be nice. I am thinking that just adding the 25 may be the way to go. This has just been an issue as of 01/01/13 that we are seeing. Thanks for your input!! I have an interesting article about this 2013 issue one of our providers questioned me on that I would love to repost, but not sure of the legalities of reposting these things..

  10. #30
    Default
    You can link to it if it's online, but if you have to attach a file, I don't know. I would think that as long as you cited the source, you'd be okay, but don't quote me on that...

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