EM Coding Alert

Question: If a patient comes in for family planning counseling, and our pediatrician administers a Depo-Provera shot at the end of the encounter, can we bill 99403 with modifier 25 along with the shot and the administration?

Wisconsin Subscriber

Answer: Yes, though you may not need to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on the preventive medicine evaluation and management (E/M) service.

Assuming the only service your provider provided to the patient in the encounter was contraceptive counseling, and providing you meet all the code requirements and payer guidelines allow, you can bill one of the risk factor reduction codes 99401-99403 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure …) based on the amount of time spent on the counseling, along with 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) for the Depo injection. And you’ll also code J1050 (Injection, medroxyprogesterone acetate, 1 mg) for the drug supply.

Using the modifier should not be necessary, as National Correct Coding Initiative (NCCI) edits do not indicate that 96372 is a column 2 code to 99403. However, a specific payer may require you to show that the counseling service was significant and separate from the Depo administration, so you will have to check that payer’s guidelines.