Part B Insider (Multispecialty) Coding Alert
Don't Let Injection Coding Errors Leave A Hole In Your Reimbursement
Denials are a sure thing if you don't report 90782, 90471, and vaccine G codes appropriately 1. B12 Injections: Understand Tricky Coding Policies Although coding a B12 injection may seem simple, the different carrier guidelines make reporting this service - and getting paid for it - frustrating for many practices. 2. Know Which Vaccine Codes Payers Accept If the physician administers a vaccination, make sure you know whether the patient has a private or Medicare insurer before you assign a code.
Scenario: Your physician administers both flu and pneumonia vaccinations to a Medicare patient. You report G0008 and G0009 for the shots, Center says. You also list supply codes 90658 (Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use) and 90732 (Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use). And link V04.81 (Need for prophylactic vaccination ...; influenza) to G0008 and 90658, and V03.82 (Need for prophylactic vaccination ...; streptococcus pneumoniae [pneumococcus]) to G0009 and 90732, she adds.
You should assign 90471 for the first administration, such as a hepatitis B vaccine. Use add-on code 90472 for any additional shots, like a tetanus or diphtheria injection. 2005 Addition: Coders should also be aware that CPT 2005 adds two new immunization codes for you to work with:
3. Muscles Count When Coding Trigger Points If the internist provides trigger point injections to treat a patient's pain, select the correct code based on the number of muscles the physician treated, not the number of injections he gave. When - And When Not - To Report An E/M An office visit often determines whether a patient needs a trigger point injection. Thus, you may report the appropriate E/M code (99201-99215), because the visit's primary purpose wasn't giving the shot, Center says.
If your injection coding expertise could use a booster shot, check out these three field-tested strategies for success.
Injections are an unavoidable part of most practices, and your reimbursement hinges on how well you understand CPT's injection codes. Follow this expert advice to code shots for B12 vitamins, vaccinations and pain.
Most Medicare payers, such as Noridian Administrative Services, accept 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for the B12 administration, and J3420 (Injection, vitamin B-12 cyano- cobalamin, up to 1,000 mcg) for the drug.
Downside: Nearly all Medicare and private carriers refuse to pay for the injection code if you report an E/M code, such as established patient code 99211, on the same day. This rule applies even if you attach 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.
"I would not recommend reporting an E/M with a B12 shot," says Lisa Center, CPC, quality review coordinator for Freeman Health System in Joplin, Mo. "If the nurse gives only a shot, I would bill only for the administration (90782) and drug code (J3420)."
Remember that CMS includes the same number of RVUs that 99211 carries with 90782, effectively bundling the two codes. In addition, Medicare generally reimburses for 90782 only if the physician bills for no other payable service on the same day.
Exception: You can also report the drug code J3420.
Caution: "On rare occasions when the patient brought in the drug, and we billed only 90782 without the J code. Medicare as well as other carriers occasionally rejected the claim," says Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla. But Medicare paid after an appeal, she adds.
"I am sure that they thought we wouldn't appeal such a small dollar amount, but we appealed everything based on principal," Pride says. "If we deserved to get paid, no matter how big or small the amount, we fought for it."
Good news: If you're able to report 90782, you should expect more payment than in previous years. Reimbursement for the code ranges from $25 to $40, depending on location. This price is up from the $3 or $4 most insurers once paid.
Typically, Medicare pays only for flu, pneumonia and hepatitis B vaccine codes:
Exception: Medicare will reimburse physicians for other vaccines or inoculations, such as the anti-rabies treatment or tetanus anti-toxin, when the provider administers the vaccine to treat an injury or direct exposure to a disease.
Therefore, if you report vaccine administration for injury or exposure, or if the patient has a private insurer that doesn't follow Medicare guidelines, you should use the following codes:
2005 Revision: Coders should note that CPT 2005 revised the descriptors for 90471 and 90472 to exclude jet injections. After Jan. 1 you can no longer report these codes if your physician administers a jet injection.
For instance, if the physician administers a single injection to a patient's back muscle, you should assign 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]). This code represents any number of shots, so you should report the code only once.
On the other hand, 20552 describes only "one or two" muscles. If the internist treated three or more muscles, make sure you report 20553 (... single or multiple trigger point[s], three or more muscles).
Tip: Be sure you attach modifier -25 to the code, Center says. The modifier shows that the E/M was separate from the injection.
Prevent denials: If the patient's encounter is principally for the injection, you should not bill an E/M unless the physician treats an additional problem during the visit. For instance, you might report an E/M visit if the patient also complains of recent dizziness (780.4) that may be related to his high blood pressure (401.x, Essential hypertension).
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