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Reader Question: Injection and E/M

Question: I don't employ a nurse and therefore perform all allergy injections myself. May I report 95115 and 99211 for this service?

California Subscriber

Answer: Per CPT guidelines, 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." If all that is provided is the injection, a separate E/M service may not be reported, whether a physician or nurse administers the medication.

If an additional, separately identifiable E/M service occurs during the same visit as 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or any other allergen immunotherapy service, the appropriate-level E/M code must be reported with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended. A separate diagnosis attached to the E/M may help expedite payment and should always be included when applicable.

Code 99211 (Office or other outpatient visit for the evaluation and management of an established patient ) is often called the "nurse-visit code," but a physician may also report the service. Payers evaluate E/M claims, including those appended with modifier -25, based on the available documentation. If a minimal E/M service is provided that does not meet the requirements of 99212-99215, 99211 may be appropriate.

However, some payers stress that to be paid, an E/M service provided with an injection must meet the strict definition of modifier -25 (the service must be separately identifiable and significant). For these payers, a claim of 99211 or even 99212 with modifier -25 appended may not qualify as significant and therefore may not be reimbursed. In addition, some third-party payers may specify contractual limitations on billing injections and E/M services on the same day.

- Published on 2002-03-01

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