EM Coding Alert
Does This Case Call for E/M and Immunotherapy Codes?
Question: A patient comes to the office for his allergy shot. He complains of an earache after swimming, so the doctor performs an evaluation and management (E/M) service focused on the otalgia complaint. Can we bill an E/M with a 25 modifier in addition to the immunotherapy injection? South Dakota Subscriber Answer: Allergy testing codes and CPT® codes for allergy immunotherapy injections include the work of a standard E/M service during that same encounter. Because of this, you should not bill a separate E/M office visit code for the time spent talking with the patient about the risks and benefits of the allergy treatment or waiting for the test result — especially if the test or injection was the reason for the scheduled visit. Caveat: There might be times when your physician provides a separate service in addition to the allergy test or treatment. If you have sufficient documentation of two separate and distinct services, you can possibly report a separate E/M code from 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) 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 to explain to the payer that a separate service was performed in addition to the allergy service. Include all documentation to support your billing. In this case, as long as the documentation supports the performance of two separate and significant services — the allergy immunotherapy for the patient’s allergies and the evaluation of the patient’s ear complaints that are truly significant and separately identifiable from the allergy care — you can bill an E/M code with modifier 25 in addition to the allergy shot administration. Just make sure you attach the otalgia diagnosis to the E/M code, and make sure the documentation reflects a history, exam, and medical decision making (MDM) for the ear complaint.
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