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Therapeutic injection and Immunization admin

  1. #1
    Default Therapeutic injection and Immunization admin
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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.

  2. #2
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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?
    Barbara Haskins CPC

  3. Default
    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

  4. #4
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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.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    National Advisory Board Member 2018-2021, Region 6 Great Lakes
    Minneapolis AAPC Chapter, Education Officer 2018
    AHIMA ICD-10-CM/PCS Trainer
    AAPC National ICD-10 Trainer

  5. #5
    Default
    Quote Originally Posted by kforkismet View Post
    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 by bhaskins1; 10-28-2008 at 10:28 AM.
    Barbara Haskins CPC

  6. Default
    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

  7. #7
    Default
    Quote Originally Posted by kforkismet View Post
    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!
    Barbara Haskins CPC

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    Kind of makes hula-hooping seem such an easy event, LOL
    Kris

  9. #9
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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

  10. #10
    Smile
    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!
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    National Advisory Board Member 2018-2021, Region 6 Great Lakes
    Minneapolis AAPC Chapter, Education Officer 2018
    AHIMA ICD-10-CM/PCS Trainer
    AAPC National ICD-10 Trainer

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