# issues when billing multiple injections on claim form



## ollielooya (Dec 8, 2011)

Patients who visit our pain management doctor are sometimes in the office many hours over the course of which multiple injections may be administered.   We are faced with two ways of billing:  bill out  one line with modifier 59  on multiple lines or 2)  bill with one 96372-59  x number of units.  Both methods result in issues of either duplicate denials (especially when splitting the claim over into a new page) or by billing one line with multiple units and attaching modifier 59 (not all the injections will pay).  I always place a description in box 19, yet the claims are never processed cleanly and we have to call and explain to customer service that the injections "spilled" over into a 2nd page of the claim.  We try to keep all injections on one page, but sometimes this just won't work. So, we're continally on the phone explaining the issues to customer service reps.  Wish the claim form had more than six line items per page. Surely, there must be a simpler way to avoid these denials.  IS there a workaround?  Would this be something that could be taken up as a contractual issue, or?????

---Suzanne E. Byrum CPC


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## mitchellde (Dec 8, 2011)

ollielooya said:


> Patients who visit our pain management doctor are sometimes in the office many hours over the course of which multiple injections may be administered.   We are faced with two ways of billing:  bill out  one line with modifier 59  on multiple lines or 2)  bill with one 96372-59  x number of units.  Both methods result in issues of either duplicate denials (especially when splitting the claim over into a new page) or by billing one line with multiple units and attaching modifier 59 (not all the injections will pay).  I always place a description in box 19, yet the claims are never processed cleanly and we have to call and explain to customer service that the injections "spilled" over into a 2nd page of the claim.  We try to keep all injections on one page, but sometimes this just won't work. So, we're continally on the phone explaining the issues to customer service reps.  Wish the claim form had more than six line items per page. Surely, there must be a simpler way to avoid these denials.  IS there a workaround?  Would this be something that could be taken up as a contractual issue, or?????
> 
> ---Suzanne E. Byrum CPC


can you give an example of the codes for a typical claim?


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## ollielooya (Dec 8, 2011)

Debra, thanks for your reply AGAIN!!  When I first started looking to the forum for answers you were answering another thread concerning ways of inputting data on the claim form.  The discussion was the propriety of single line entries with modifier 59 as opposed to unit billing which you advised not too based on propriety of "units".  So, for the most part have been billing it that way.  The injections get paid, but it takes a lot of administrative paper work to follow thru.  Some insurance companies have suggested (but not confirmed) that unit billing MIGHT work?  So here is an example of a chart note.

An injection of  phenobarbital 130 mg IM and Vistaril 50 mg IM were given. She was monitored for one hour and noted minimal improvement headaches. Another injection of phenobarbital 130 mg was given and she was monitored for another hour without any improvement in headaches. Then 3 mg of Ativan was given and she was monitored for another hour without any improvement headaches. Then 3 mg of Dilaudid IM and 50 mg of Benadryl IM were given. She was monitored for one hour with marginal improvement in her headaches. Patient underwent occipital blocks without any improvement headaches. Then she had 3 mg of Dilaudid IM and was monitored for 15 minutes. Headaches significantly improved. 

Patient was discharged in stable condition and had a driver.  Vitals at the time of discharge were:  
Bp: 132/97.  

This service was provided on an emergency basis due to the nature of the acute headache, which had not responded to treatments at home, resulting in disruption of office schedule and delay in treating other patients.BTW, have you been able to base a conclusion on the McKEsson edits thread posted last week?

Suzanne E. Byrum CPC


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## ollielooya (Dec 9, 2011)

Trying to keep this thread alive as it was buried beneath the avalanche of new posts.  Seeking possibile solutions from others.  ---Suizanne


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## ollielooya (Dec 12, 2011)

bumping thread with 3rd request hoping for some answers. ---Suzanne


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## mitchellde (Dec 12, 2011)

Thank You I was looking for the original thread!  Ok I need to know if the phenobarb and vistaril were given in the same syringe, they normally are so that would count as 1 injection, and the dilaudid and benadryl are usually together.  So you have 5 injections.  It is more appropriate to bill as individual line items using the 59 modifier.  I am sorry about the administrative work this causes although I do not see why.  So another question is are these electronic or paper.  I have never had an electronic claim state a denial based on spilling over to a second page.  while some payers MAY pay using units and MAY even pay correctly they will also pay correctly using multiple line billing.  Many payers that one client had that use to pay using units are now rejecting for units greater than 1.  Now if in fact you do have a page issue, and you have to roll over to a second page I have found a tactic that does work, that is on page 2 the first line is listed with no modifier and the second and subsequent have a 59.  Do not ask me why but this seems to work.
I am hitting a brick wall on the Mckession issue.  I thought at first it was a modifier vs body part issue but that does not seem to work out.  I am not giving up as I remember having this problem once before and we found the answer then I just have to find my notes from that and recreate it!  It was several years ago but so much the same thing so I think the answer is right in front of us.  Thank You for keeping the thread alive!  I never have a ton of time except when I am waiting in the airport.


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## ollielooya (Dec 12, 2011)

Debra, thank you so much for reporting in.  Was so hoping that you would on these two issues.  1) billing issue.  Phenobarb and vistaril are given as two sep. injections and so are the dilaudid and benadryl is what I understand.  Claims are billed paper because providers usually want the chart notes for these type of procedures and doctor has asked us to do so.  We will try your suggestion and see what happens.  I did call Provider Relations and explain to them that we are continually getting hit by these edits and creating extra administrative work on our part for something they should be able to fix from their end for every claim we submit with the multiplicity of injections. 
McKesson issue:  Again, it has not been consistent but we are managing to get some denials overturned as a result of our submitting CMS and Local policy guidelines, but it is still hit and miss.  What isn't there any consistency here?  Higher up regional support is looking into the matter and has promised to get back to us concerning the McKesson edit issues, and we're currently still awaiting official word. Again, thanks for taking note and replying and will look forward to any add'l comments you find time to make!  --Suzanne


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