Otolaryngology Coding Alert

Why you'll now get paid for both 90780 and an E/M

Although you can expect your reimbursement to increase now that Medicare will pay for 99211 in addition to drug administration codes (90780-90788), make sure you code with caution -- CMS still will not let you report the codes together.

In the 2004 Medicare Physician Fee Schedule, which took effect Jan. 1, CMS adds 0.17 relative value units (RVUs) to therapeutic infusion and injection codes 90780-90788. The RVU increase equals the RVUs for E/M code 99211 (Office or other outpatient visit for the E/M of an established patient ...). Therefore, Medicare considers 99211 included in the codes when you bill them on the same day.

Pick Up an Extra $21

Because infusion and injection codes (90780-90788) now include the same RVUs as 99211, you will get paid for an infusion or injection and E/M service every time you report 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) or 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).

The bottom line: You'll now pick up the national average of $21 that 99211 pays when you submit codes 90780-90788.

Previously, most allergy practices didn't bill 99211 on the same day as 90780-90788 because Medicare considers the E/M service included in the procedures.

"I cannot think of a situation in which there would be a significantly separate service that would be provided by a nurse during the administration of an injection or infusion," says Bruce Rappoport, MD, CPC, who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.
 
Watch Out for Modifier -25

In the rare case that a practice bills for 90780-90788 in addition to a higher-level office visit (for example, 99212), coders should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, according to CMS transmittal 34, dated Dec. 24, 2003.

Red flag: Remember that you can bill only a physician's service, not the nurse's, with a 99212 or higher, says Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla. Also, Medicare would most likely pay only for the E/M code, not the infusion or injection code.