Get Paid Separately for Allergy Shots and Visits

According to CPT and Medicare, practices can get paid for significant, separately identifiable E/M services performed at the same time as an allergy shot. However, convincing your carrier to reimburse both services can be difficult.
 
If the physician is evaluating the patient for the same condition for which the shot is given (for example, allergic rhinitis, 477.x), it may be even more difficult to obtain separate payment for the E/M service and 95115 (professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95117 (... two or more injections).

Modifier -25 Unlocks Reimbursement
 
Coding guidelines issued by the AMA and the Centers for Medicare & Medicaid Services (CMS, formerly HCFA) are clear. First, in the extended descriptor for modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), the CPT manual clearly states that "the patient's condition [may] require a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date."
 
The introduction to the allergen immunotherapy section states that "Codes 95115-95199 include the professional services necessary for allergen immunotherapy. Office visit codes may be used in addition to allergen immunotherapy if other identifiable services are provided at that time."
 
The Medicare Carriers Manual also indicates that both services may be billed. Section 15050 states, "Visits should not be billed with allergy injection services 95115 or 95117. Unless the visit represents another separately identifiable service, you are to rely on the use of modifier -25 as the only means through which payment can be obtained for visit services provided on the same day as allergen immunotherapy series."
 
Although this issue seems straightforward enough for CPT and CMS, many carriers still deny claims when office visits are performed at the same time as allergy shots. "Until recently we couldn't get paid at all for 95115 and an office visit," says Lori Wyvill, office manager in the general allergy practice of Suzanne Weakley, MD, in Houston. "Trailblazer, our local Medicare carrier, now pays for both but wants to see separate diagnoses for the visit and the shot." In most cases, these separate diagnoses do not pose any problems, Wyvill says.
 
For example, many patients have asthma as well as allergies, so the follow-up visits relate to asthma, and the physician decides if it would be safe to administer the shot [...]

- Published on 2001-09-01