# ov with modifier 25  and  injection



## Bonnie Owen

I was told by a fellow co worker that Medicare allows an office visit with modifier 25 attached when  billing an  injection of  a drug ( example Kenalog for allergies/rash) to get the adm fee 96372 paid. I disagree. I say content of service and modifier 25 should not be used. I know Medicare  now covers adm fee on vaccines with OV w/ or w/o mod 25  for the adm fee,  but I have never heard of adm fee  getting billed and paid for by Medicare with OV with other injections , not vaccines. I am  not talking  about trigger points or injections  into hips/  knees. Drugs like depo medrol, Kenalog, tordol that go  into  the  IM.


----------



## btadlock1

Bonnie Owen said:


> I was told by a fellow co worker that Medicare allows an office visit with modifier 25 attached when  billing an  injection of  a drug ( example Kenalog for allergies/rash) to get the adm fee 96372 paid. I disagree. I say content of service and modifier 25 should not be used. I know Medicare  now covers adm fee on vaccines with OV w/ or w/o mod 25  for the adm fee,  but I have never heard of adm fee  getting billed and paid for by Medicare with OV.



If you have a separate, significantly identifiable E/M service, apart from simply administering an injection, is reportable with modifier 25. It doesn't even have to be for a different diagnosis than what led to the shot - if a patient comes in with a problem, and the doctor decides to treat the problem with a shot (like Kenalog, or Rocephin), you can bill the appropriate level of problem-oriented E/M service with a 25 modifier in addition to the therapeutic/prophylactic injection admin. You technically don't need a 25 modifier when billing preventive visits with vaccine/toxoid administrations. Medicare follows CPT guidelines, to my knowledge.


----------



## eadun2000

Bonnie Owen said:


> I was told by a fellow co worker that Medicare allows an office visit with modifier 25 attached when  billing an  injection of  a drug ( example Kenalog for allergies/rash) to get the adm fee 96372 paid. I disagree. I say content of service and modifier 25 should not be used. I know Medicare  now covers adm fee on vaccines with OV w/ or w/o mod 25  for the adm fee,  but I have never heard of adm fee  getting billed and paid for by Medicare with OV with other injections , not vaccines. I am  not talking  about trigger points or injections  into hips/  knees. Drugs like depo medrol, Kenalog, tordol that go  into  the  IM.



Wow.  Of course if you have a separate identifiable evaluation and management, then you can use mod 25 for the 96372.  Where are you getting that you cannot do that?  A procedure was performed.  It should be coded.


----------



## mitchellde

Absolutely.  CMS released a transmittal on this back in 2004 that it was acceptable to use a 25 modifier on the office visit when billing a 96372 as long as the parameters of the 25 modifier had been met.  If the patient is scheduled for an injection then no there can be no ov in addition as the injection was pre planned.


----------



## Bonnie Owen

Most other insurance companies consider the  drug adm fee content of service of the OV and will not pay seperately.


----------



## btadlock1

Bonnie Owen said:


> Most other insurance companies consider the  drug adm fee content of service of the OV and will not pay seperately.



Really? Maybe you should check for a contracting issue, then - *all *of our payers cover both. I honestly can't think of a single one that won't pay both when they're billed properly. 

If anything, the _*OV*_ denies as bundled to the injection admin - and that's only when the 25 modifier is forgotten. There's absolutely no reason your injection admin should be denying, unless you're also billing for another _procedure_ during the same visit, and forget to add a 59 modifier to 96372, or if you're only billing a 99211, in which case, no - you can't bill _that_ OV with 96372.


----------



## eadun2000

btadlock1 said:


> Really? Maybe you should check for a contracting issue, then - *all *of our payers cover both. I honestly can't think of a single one that won't pay both when they're billed properly.
> 
> If anything, the _*OV*_ denies as bundled to the injection admin - and that's only when the 25 modifier is forgotten. There's absolutely no reason your injection admin should be denying, unless you're also billing for another _procedure_ during the same visit, and forget to add a 59 modifier to 96372, or if you're only billing a 99211, in which case, no - you can't bill _that_ OV with 96372.



I agree with you 100%.  If it is billed correctly, then it should be paid.  I have NEVER had one denied/bundled when a modifier 25 was added and/or 59 if another procedure was done on that same visit.  Scares me to think how much revenue is just "walking out the door".  Wow!


----------



## Bonnie Owen

Thank you, I have been misinformed.


----------



## Bonnie Owen

Denial from  BC today. OV w/ mod  25, 96372,  and J code. 96372 denied inclusive  to OV. No other procedures this  day, thus no need for mod  59.


----------



## mitchellde

Bonnie Owen said:


> Denial from  BC today. OV w/ mod  25, 96372,  and J code. 96372 denied inclusive  to OV. No other procedures this  day, thus no need for mod  59.



What was the dx, the visit level and the drug?


----------



## btadlock1

Bonnie Owen said:


> Denial from  BC today. OV w/ mod  25, 96372,  and J code. 96372 denied inclusive  to OV. No other procedures this  day, thus no need for mod  59.



99211? That's the only OV that should have caused that denial. (NCCI edit) 

What did your claim look like - list all of the CPT's, units, and Dx codes...a few of us might be able to help you find what's triggering it.


----------



## Bonnie Owen

I will check and get back with  you. Thanks. Waiting to see what Medicare  did on  a claim.


----------



## btadlock1

Bonnie Owen said:


> I will check and get back with  you. Thanks. Waiting to see what Medicare  did on  a claim.



Please do! My background is in commercial follow-up/appeals, so I'd be glad to try to help you get it paid. Just let me know!


----------



## Bonnie Owen

*Modifier 25 on E/M with 96372*



Bonnie Owen said:


> I was told by a fellow co worker that Medicare allows an office visit with modifier 25 attached when  billing an  injection of  a drug ( example Kenalog for allergies/rash) to get the adm fee 96372 paid. I disagree. I say content of service and modifier 25 should not be used. I know Medicare  now covers adm fee on vaccines with OV w/ or w/o mod 25  for the adm fee,  but I have never heard of adm fee  getting billed and paid for by Medicare with OV with other injections , not vaccines. I am  not talking  about trigger points or injections  into hips/  knees. Drugs like depo medrol, Kenalog, tordol that go  into  the  IM.



Sorry it took so long to get back with the example:      99202 mod 25      J1040 X 1   and   96372             dx: 477.9/478.19/786.2. Blue Cross/Blue Shield      paid OV, paid J code and denied 96372 as CO97, inclusive to other service.


----------



## btadlock1

Bonnie Owen said:


> Sorry it took so long to get back with the example:      99202 mod 25      J1040 X 1   and   96372             dx: 477.9/478.19/786.2. Blue Cross/Blue Shield      paid OV, paid J code and denied 96372 as CO97, inclusive to other service.



Interesting - what did they tell you when you called? When I ran those in their claim editor, it shows to allow all 3 - I attached a screen shot of it.


----------



## Bonnie Owen

*E/M w 96372*



mitchellde said:


> What was the dx, the visit level and the drug?



99214 dx 250.00,  251.2 and 401.9. J3420- B-12 injection  with dx 266.2 and 96372 same dx.


----------



## btadlock1

Bonnie Owen said:


> 99214 dx 250.00,  251.2 and 401.9. J3420- B-12 injection  with dx 266.2 and 96372 same dx.



Did the B-12 deny?


----------



## Bonnie Owen

*e/m mod 25 w/ j code and 96372*



mitchellde said:


> What was the dx, the visit level and the drug?



I posted this yesterday but do not see the listing so I am reposting info. 99202 mod 25, dx 477.9, 478.19, 786.2 with J1040 and 96372 same dx. 96372 denied inclusive to E/M.


----------



## btadlock1

Bonnie Owen said:


> I posted this yesterday but do not see the listing so I am reposting info. 99202 mod 25, dx 477.9, 478.19, 786.2 with J1040 and 96372 same dx. 96372 denied inclusive to E/M.



You posted that one a few days ago - BCBS's claim editor shows that all three of those should pay - what did their CSR's tell you when you called? I think that denial is an error.

The one you posted yesterday was for J3420 - did the B-12 deny? If so, the injection admin won't be covered either. 

I suggest calling BCBS and asking about these denials. They're not correct if the drug codes are paying.


----------



## Bonnie Owen

*denial*



btadlock1 said:


> Did the B-12 deny?



B12 did not deny, it's 96372 denying cos. Where are you located?


----------



## btadlock1

Bonnie Owen said:


> B12 did not deny, it's 96372 denying cos. Where are you located?



Lubbock, Texas...You?


----------



## btadlock1

*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).


----------



## cdavenport249

*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....


----------



## mitchellde

You are correct the nurses time involved in all aspects of the injection are included in the injection administration code.


----------



## lseiter

*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....


----------



## Jacque McCulley

*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


----------



## alosiewski

*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!!


----------



## btadlock1

alosiewski said:


> 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!


----------



## alosiewski

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..


----------



## btadlock1

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...


----------



## alosiewski

This is the article from the AAFP... http://blogs.aafp.org/fpm/gettingpaid/entry/pay_attention_or_don_t


----------



## AGMoore

*OV Preventive visit & vaccines*


January CCI edits have changed the indicator to "1" modifer needed on preventive vists and other E/M visits: 
99201 thru 99205   E/M visit new patient
99212 thru 99215   E/M visit established patient
99241 thru 99245   Office consultation
99251 thru 99255   Consultation Inpatient
99281 thru 99281   Emergency department visit
99381 thru 99387   Preventive medicine visit 
99391 thru 99397   Preventive medicine reevaluation visit
99401 thru 99409   Preventive counseling services
99411 thru 99412   Preventive counseling service group setting
99420                    Administration and interpretation of health risk


when these codes are billed on the same day with:
CPT   90471 & 90472 immunization admin w/o counseling & each additional vaccine
CPT   90473 & 90474 immunization admin intranasal or oral & each additional vaccine 
CPT   90460 & 90461 immunization admin w/counseling & each additional vaccine

In Pediatric practice sometimes patient is billed preventive and sick E/M code and vaccines on the sameday according to CCI edits both visits need a modifier 25. Not sure what to do in these cases, never billed this way before. Does not seem correct. Need some input and ideas.


----------



## alosiewski

This is what i came up with, as well.  I am equally confused.  It just doesn't make logical sense to require the modifier on both the exam AND the office visit codes, especially when they are together.  We often see patients for preventive, vaccine, and chronic disease appts at the same time, also.  I am trying to send a few claims this way and waiting to see if insurance pays or not.  I will certianly post what I come up with, but would be thrilled if somebody else comes up with something first!!


----------



## sfgdfgdfgsdfffds

*Pain management billing*

I am having and issue with AL bcbs we are billing an established E/M with and injection and they are paying the injection and stating the E/M is bundled. There is a mod 25 on the E/M. I am new to billing for pain management can we not bill and e/m with and epidural injection on same date of service or is there another modifier that I should be using.


----------



## alosiewski

Are the DX codes linked appropriately?  I would make sure that the E/M code has a differant DX than the injection (AND also has the modifier 25).  The modifier is indicating that the E/M is for a separately identifiable E/M service.


----------

