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Consider the Need to Administer Medication When Coding 99211

Published on Thu Jun 12, 2014

Question: We have a patient in our practice that comes in for her prothrombin time (PT) test and her B12 shot at the same time.  The doctor looks over the PT results and instructs the patient.  We bill a 99211 and 85610 with modifier QW for the prothrombin time and also a 96372 and J3420 for the B12.  Medicare will not pay for the 99211 and the 96372.  Am I coding incorrectly?

Illinois Subscriber 

Answer: Part of your coding is incorrect if the physician is only reviewing the PT results to determine if the therapy is working. If it is or isn’t working and the doctor gives further instructions, you’ll report 85610 (Prothrombin time). Billing 99211 (Office or other outpatient visit for the evaluation and management of an established patient, …) would not be appropriate in this situation. 
 
Therefore, the B12 injection (J3420, Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg) and administration would be the only other services billable that day. You cannot bill 99211 with the administration of a medication. 
 
If your doctor is reviewing Coumadin and making any adjustments to the medication you may be able to bill 99212 (Office or other outpatient visit for the evaluation and management of an established patient, …) with the PT check and B12 injection, assuming he documents the appropriate history, exam, and/or medical decision making. 
You cannot bill 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) with the office visit code. 
Attach modifier 25 (Significant, separately identifiable evaluation and management service …) to the E/M code you report if there was a separately identifiable service provided by the physician. You will know that the visit is separately identifiable based on the documentation of the physician. The visit could be more detailed in nature, thus, the justification to bill the modifier 25 with the injection codes.

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