# Need Help Please!



## MsMaddy (Aug 13, 2008)

A Pt Was Seen By Ma Only And Gave The Pt Zostavax And 
We Submitted To The Ins. As 

99211
90736
G0008

Dx- V05.4

We Got A Call Today From Blue Cross Saying That We Have To
Add A Modifier To 90736 In Order To Get Paid By Blue Cross.  Keep In 
Mind Pt Has Medicare As Prim And Bc As 2ndry.  Can Anyone Tell Me
What Modifier There Talking About ?  And Bc Said They Can't Tell Us
Which Modifier But Is The 2nd One In The Modifier List.  I Don't Know Why We Need Modifier It Was Nurse Visit Only.

Thank You All In Advance.

Msmaddy


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## rthames052006 (Aug 13, 2008)

madlen said:


> A Pt Was Seen By Ma Only And Gave The Pt Zostavax And
> We Submitted To The Ins. As
> 
> 99211
> ...





Msmaddy,

That doesn't sound right to me you should have the modifier (25)  on the visit not the immunization. 

Why are you billing a minimal visit anyway?  Did the nurse just give the immunization. The g0008 is not the correct code thats the admin code for the flu shot. You need 90471 not g0008.


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## dmaec (Aug 13, 2008)

GY modifier on the zoztavax - Medicare isn't going to pay it.  You'd need a .25 on the office also - however, I don't see an OV - I see immunization only (from the info you provided)
_{that's my opinion on the posted matter}_


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## MsMaddy (Aug 13, 2008)

Yes, the nurse only gave the immunization pt was not seen by the Dr.  So 
do we still use mod 25 and use 90471 for admin of immun. 

Thank You Again
Msmaddy


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## dmaec (Aug 14, 2008)

if you're going to charge the E/M, yes - you'd need a .25 modifier on it - and yes, it's the 90471 admin code


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## mbort (Aug 14, 2008)

you mentioned that the patient was seen by the MA...I dont believe that MA's qualify as a "nurse" to justify a "nurse" visit.


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## Lisa Bledsoe (Aug 14, 2008)

You should not code 99211 with administration codes...  Also, you need to get the denial from Medicare first before billing the secondary (I believe), so it needs to go to Medicare first to get the denial.  And G0008 is not the admin code as Donna said.


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## MsMaddy (Aug 14, 2008)

Dear Donna,

I used the GY Modifer on Zostavax as you mentioned and we resubmitted
the claim as:

99211
90536
90471

FYI
The BC ins person called us back saying that was a wrong modifier, she 
said again it the 2nd modifier in the list.  We Asked which book cpt or 
hcpcs? She said I can't tell you then, she whispered cpt book.  So we gave
the modifier 22, And she confirmed it that was the right code.  Modifier 22
it seems to be for procedure that require more work.  Are you sure that it is 
OK to use modifier 25 with level 99211 since it was nurse only visit and all she did was gave the vaccine?

Thank You Again
MsMaddy


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## mkj2486 (Aug 15, 2008)

We were always told that in order to charge a nurse visit, there has to be documentation in the patients record that the nurse performed an exam of some sort.  If all the MA did was give an immunization you cannot charge was is considered an E/M (99211).  (I am also not sure about MA's charging a nurse visit.)  From what you said you should only be charging the administration code and the zostavax vaccine.  By the way, Medicare part D does pay for this, so if the patient has Medicare Part D it is covered.


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## dmaec (Aug 15, 2008)

madlen said:


> Dear Donna,
> 
> I used the GY Modifer on Zostavax as you mentioned and we resubmitted
> the claim as:
> ...



MsMaddy - Like I said, I don't see an OV - on what you presented before. I see an immunization only.  I wouldn't code the 99211 BUT as I said, if you do, if you have documentation supporting it - it would need a .25 due to the immunization.  
Also, my zoztavax CPT code I use is 90736, not 90536 (there isn't a 90536)
the 90736 needs the GY on it for Medicare.  
there isn't any service provided in your scenario that justifies the use of the 22 modifier.  22 modifier is NEVER appended to the office visit and the injection does not require "more work"... I don't usually say someone is wrong - but the lady at BCBS  is ...... well, wrong... 
if I was coding this I would put:
90736.GY
90471
with dx:V04.89

_{that's my opinion on the posted matter}_


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## marygoodsell (Aug 15, 2008)

If only the vaccine is given, there is no need to code the visit.  When coding vaccine, you also have to code the administration as well.  Use code 90736 for vaccine and 90471 for administration.  This is not a flu vaccination so you would not use G0008.  There should be no modifier if no E/M service was rendered.

It states in my step-by-step coding book "IF THE ONLY SERVICE IS ADMINISTRATION OF A VACCINE AND NO OTHER SERVICE IS PROVIDED, DO NOT CODE AN E/M.  RATHER ONLY CODE FOR THE ADMINISTRATION OF THE VACCINE AND THE VACCINE PRODUCT."

It also states the "If a E/M service was provided, some third party payers require a -25 modifier on the E/M code."  It would not be -22 modifier.

Also, it states "FOR MEDICARE PATIENTS, YOU WOULD ONLY REPORT AN ADMINISTRATION CODE FOR AN IMMUNIZATION WHEN NO OFFICE SERVICE CODE WAS REPORTED.  MEDICARE POLICY STATES THAT IF AN OFFICE SERVICE IS REPORTED, THE OFFICE SERVICE CODE INCLUDES THE ADMINISTRATION OF AN IMMUNIZATION."

I hope this helps some.


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## MsMaddy (Aug 17, 2008)

Donna,

Thank you for your input, as far as documentation for ma visit only yes 
we do have documentation. And I am sorry about zostavax code it was a typo. We'll just wait for the claim that the biller sent through we'll see
if it gets denied. I agree with about the modifier 22, and we did not append it
to the office level 99211 it was on 90736 according BCBS lady.  so 
if it become denied should I coded likt this?

99211-25
90736-gy
90471

Thank you again for your help!

MsMaddy


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## MsMaddy (Aug 17, 2008)

marygoodsell said:


> If only the vaccine is given, there is no need to code the visit.  When coding vaccine, you also have to code the administration as well.  Use code 90736 for vaccine and 90471 for administration.  This is not a flu vaccination so you would not use G0008.  There should be no modifier if no E/M service was rendered.
> 
> It states in my step-by-step coding book "IF THE ONLY SERVICE IS ADMINISTRATION OF A VACCINE AND NO OTHER SERVICE IS PROVIDED, DO NOT CODE AN E/M.  RATHER ONLY CODE FOR THE ADMINISTRATION OF THE VACCINE AND THE VACCINE PRODUCT."
> 
> ...



I don't understand why 99211 can not be used to ma only visit, the doctors is present on site and it is his request for the administration even though he does not go into the room only MA does and provide the vaccine.  Thats why we use level I 99211.  According to the cpt book and the coding school I attended that is the case.

Thank for your help!

MsMaddy CPC-A


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## dmaec (Aug 18, 2008)

madlen said:


> Donna,
> 
> Thank you for your input, as far as documentation for ma visit only yes
> we do have documentation. And I am sorry about zostavax code it was a typo. We'll just wait for the claim that the biller sent through we'll see
> ...



MsMaddy - *I*wouldn't code the OV (99211), doesn't matter if the doctor is on site, this service appears to be an "immunization only" visit.  *I* would only code out the 90736.GY & 90471 with DX:V04.89.  However, if you're still going to code out the OV - then yes - it should go out as you have it above 
_{that's my opinion on the posted matter}_


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## marygoodsell (Aug 18, 2008)

If she codes for the OV, is that not fraud?


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## MsMaddy (Aug 23, 2008)

marygoodsell said:


> If she codes for the OV, is that not fraud?



Some insurance adjust of the 99211  and others like Kaiser require us to use 99211 even if it is MA visit.  Look at the 99211 in cpt book, it does not require for Dr to be present, it is only for a five minute spent performing or supervising these services and it is not a key component.

I hope this helped!

MsMaddy


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## Lisa Bledsoe (Aug 25, 2008)

madlen said:


> Some insurance adjust of the 99211  and others like Kaiser require us to use 99211 even if it is MA visit.  Look at the 99211 in cpt book, it does not require for Dr to be present, it is only for a five minute spent performing or supervising these services and it is not a key component.
> 
> I hope this helped!
> 
> MsMaddy



True - but if it is an immunization/injection only visit then you should not be coding 99211.  Check out this link:  http://www.trailblazerhealth.com/Publications/Job Aid/DocReqCPT99211JobAid.pdf


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## mmallette (Sep 4, 2008)

RI Blue Cross uses -22 modifier on injections for adults to show it is not a state supplied vaccine.  It really isn't a correct modifier, but that is how you get paid by BS (RI)


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