Internal Medicine Coding Alert

Medicare now allows same-day E/M service and allergy injection -- and your payers should, too

Coders often have trouble separating an allergy shot service from a distinctly different E/M service. If you don't find a separate E/M when your internist provides it, you cannot be expected to code for it.

But conversely, if you report a separate E/M when you should only report the injection code, you could be accused of overcoding. Before you write off another E/M service-allergy shot bundle, try these specialty-society-backed tactics.

Case study: One coder requested help for claims involving 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) and 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or CPT 95117 (... two or more injections). Insurance companies are denying the office visit as incidental to the immunotherapy injection, says Tonya Beans, medical biller for Lloyd Charles Jr., MD, in Upper Marlboro, Md.

Here's the federal lowdown on reporting E/Ms with allergy immunization codes, from National Government Services article A22072, published July 23:

"E/M codes billed with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is administered. When appropriate, use modifier 25 with the E/M code to indicate it as a separately identifiable service."

(See the NGS article for yourself online at http://www.cms.hhs.gov/mcd/viewarticle.asp?article_id=22072&article_version=6&basket=article%3A22072%3A6%3AALLERGY+IMMUNOTHERAPY+%2D+Medical+Policy+Article%3AFI%3ANational+Government+Services%7C%7C+Inc%2E++%2800308%29.)

But when is modifier 25 "appropriate," and when should you leave it off of the claim? Here's what allergy coding experts recommend.

When you report an office visit (OV) and same-day injection, CPT does not require you to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Medicare allows an office visit (OV) and injection on the same day without modifier 25.

Example: An internist sees a patient due to nasal congestion (478.19), and then the patient receives her scheduled series of two allergy injections for allergic rhinitis due to pollen (477.0). The physician performs and documents a level-two E/M service. You may report 99212 and 95117, according to Medicare rules.

Billing 99212 or any other E/M service with 95115 or 95117 is a recent turn of events. Prior to Jan. 1, 2006, Medicare designated allergy injections as global-period codes, says Robert A. Nathan, MD, president of the Joint Council of Allergy, Asthma and Immunology (JCAAI), in a members' letter. The designation meant you could not bill 95115 and 95117 with an E/M service without using modifier 25.

New way: Under new Medicare policy, 95115 and 95117 no longer have global periods. Therefore, "You are allowed to bill an E/M service (including 99211, Office or other outpatient visit for the E/M of a patient, that may not require the presence of a physician ...) with allergy injection codes without meeting the requirements for modifier 25," the JCAAI letter says. Because 95115 and 95117 include no payment for physician work, payment of a separate E/M service is appropriate.

Problem: Some commercial carriers haven't gotten the message, says Kathy Anderson, CPC, a practice consultant in Asheville, N.C. In fact, a survey conducted by JCAAI indicates practices across the United States are all having the same issues.

Although Medicare policy and CPT guidelines do not require modifier 25 on claims for higher-level E/M services and allergy injections, payers may have system edits in place that make using the modifier necessary. "We usually add modifier 25 to the E/M and have no problems getting paid," Anderson says.

Rest easy: The allergy specialty society backs resorting to modifier 25 in these situations. If you think an encounter meets the criteria for modifier 25 (for instance, the physician has provided a separately identifiable service distinct from the injection), consider resubmitting rejected claims with modifier 25, the JCAAI says.

Example: Higher-level office visits not related to the injection administration would probably qualify for modifier 25, the council says. But "make sure you have appropriate documentation."

You can even report a minimal E/M service related to immunotherapy. Providers may bill for a nurse-only 99211 when dealing with clinical issues surrounding allergy injection administration, the JCAAI says. The service could represent directing a nurse who gives injections on what to do if a patient:

• was ill,

• missed an injection, or

• had a large, local reaction or mild unreported systemic symptoms after his last injection.

Be careful: On claims involving a nurse visit related to allergy immunotherapy, don't append modifier 25 to 99211. When you bill 99211 for providing clinical advice related to the injection, modifier 25 is unnecessary and does not apply, the JCAAI says.

But the nurse must document the medically necessary E/M service that she provided.