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90772 - Is this coding correct

  1. Default 90772 - Is this coding correct
    Medical Coding Books

    Is this coding correct 99213-25, 255.41, 90772? because is been denied by the insurance.


  2. #2
    Duluth, Minnesota
    no, it's included in the office visit (no need for .25 on office either) UNLESS it's a Medicare (or what we refer to as Medicare"like" insurances/MA/PMAPs, etc). I'm curious though, what was given? (what drug).
    Donna, CPC, CPC-H

  3. Default
    What drug was given? And what is being denied, the office visit or the administration? The modifier 25 is correct. CPT guidelines state that a separate diagnosis is not necessary for administration codes when the office visit is billed with a modifier 25. (paraphrased). I see many payors deny though. What I make sure is that the office visit is paid. If they deny the office visit, then I appeal.


  4. #4
    Bridgeport, CT
    Smile 90772 with CPT 9921X-25
    The E/M service is included in the prophylactic injection, unless significant and separate per CMS NCCI edit manual. for exapmle, you do the H&P, ROS and MDM for a vitamin B-12 insufficiency and inject B-12 you would report 90772 for the injection. If then you also discuss the patient's underlying Diabetis and a separate and signifiant E/M is recorded, you would be able to report with modifier 25.

    I hope this helps.

  5. #5
    Duluth, Minnesota
    for regular/commercial insurances the 90772 is included in the E/M if there is an E/M- no modifier .25 is needed on the office visit because it shouldn't be charged separately. Even if they have Diabetes and B12 defieciency, and get a B12 injection - you can't code the 90772 - it's included in the E/M. However -Medicare and medicare"like", require the injection to be billed, and add a modifier .25 on the E/M
    (who's to say whether they pay or not, but they DO want it billed out)
    Last edited by dmaec; 07-09-2008 at 07:31 AM.
    Donna, CPC, CPC-H

  6. #6
    Greeley, Colorado
    Personally, I would bill both the E/M with mod -25 and 90772. What drug was given? Which code was denied? What insurance are we talking about? Bottom line, it's going to depend on who the payer surprise there!

  7. #7
    Duluth, Minnesota
    LOL - very good point Lisa! I guess we're just used to crossing it off (knowing they won't pay) for certain insurances, and leaving it on and adding a modifier .25 for other insurances for others - (still knowing)
    Donna, CPC, CPC-H

  8. #8
    Modifier 25 indicates significant, separately identifiable e/m was provided. If this is the case you also have to bill the appropriate J code to identify what was given. I have never known a 90772 to be paid without identifying the drug. If they deny either charge you can appeal with medical records showing the documentation of the office visit to justify the charge for the e/m. If the Dr. didn't document an e/m and the patient was only seen for the purpose of giving the shot, the denial is appropriate.
    Barbara Haskins CPC

  9. Default
    Thank you everyone for all the info, the insurance is Medicaid, what is being denied is the O/V and the drug is Lupron 11.25mg (but mom brings the drug), i don't think i need a J code because mom just come for the administration.

  10. #10
    Quote Originally Posted by View Post
    Thank you everyone for all the info, the insurance is Medicaid, what is being denied is the O/V and the drug is Lupron 11.25mg (but mom brings the drug), i don't think i need a J code because mom just come for the administration.
    ***** in regards to billing the J code... We bill the drug code at $.01 just to identify for Medicaid what drug was given. So you are not looking for reimbursement for the drug so much as you are telling Medicaid what you administered. I am talking about North Carolina Medicaid... I know each state is different.

    ***** in regards to the OV, I would appeal with the Dr. notes if they documented a separate e/m and not just that they administered the drug. If no e/m is documented then the denial is correct.

    Hope this helps...
    Barbara Haskins CPC

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