Pediatric Coding Alert

Allergies and allergic asthma have been on the upswing among children. But the most commonly used codes (95115, 95117) don't pay well enough unless an office visit can be billed as well, many groups feel. 

For physicians who provide antigens -- mainly allergists -- report CPT 95165 (professional services for the supervision and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]) for providing the dose. Bill this code by units. If you don't mix the antigens -- and most pediatricians don't -- use 95115 (professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95117 (... two or more injections). You cannot bill for storing the antigens.
 
Allergy Introduction and Office Visit Billing

 

You may not bill an office visit when providing allergy shots unless you provide a separately identifiable and significant service, says Paula Ziemski, CPC, coding and compliance educator at the University of Pittsburgh Medical Center in Pennsylvania. "You need to do something extra to bill an office visit," Ziemski says. "In general we tell our pediatric practices they can't do it when they give allergy shots." 

Carel Martin, CPC, insurance supervisor for Cle Elum Family Medicine in Cle Elum, Wash., notes that many commercial payers follow national Correct Coding Initiative (CCI) edits and bundle most E/M services with 95115 and 95117. "You can't bill an office visit code with these companies," she says. She believes it's inappropriate to bill an E/M service with 95115 or 95117 unless the patient comes in for another problem altogether. "It's all built in to the allergy injection codes." 

Some pediatric practices have stopped giving allergy shots because the remuneration is so little compared to the time expended.

 "A lot of patients now provide their own serum," notes Brenda Mason, billing manager for Northpoint Pediatrics in Indianapolis. And when patients bring in their own serum it becomes too costly to give the shots because 95115 and 95117 pay so little. These codes are no longer on Mason's superbills. Because the group could not bill an office visit with the allergy injections, she says it was simply too expensive to provide allergy shots.

 

E/M May Be Warranted
 
CPT does not specify that the additional service be either significant or separately identifiable. Rather, CPT's introduction to the allergen immunotherapy codes states, "Office visit codes may be used in addition to allergen immunotherapy if other identifiable services are provided at that time" [emphasis added]. 

 

Charles Scott, MD, FAAP, a practicing pediatrician at Medford Pediatric & Adolescent Medicine in Medford, N.J., interprets the descriptor literally. "We bill a nurse visit in addition to giving the injections. The nurse has to evaluate the child first, and then again after the shot." For these visits, he bills 99211 (office or other outpatient visit ... that may not require the presence of a physician) and 95115 or 95117.

Dari Bonner, CPC, CPC-H, CCS-P, CEO of Xact Coding and Reimbursement Consulting in Port St. Lucie, Fla., agrees that you can bill a nurse visit if the nurse provides an assessment and documents it. 

 

For example, a nurse administers an allergy shot and sends the patient into the waiting room for 20 minutes. He or she then looks at the site to make sure no reaction has taken place. "You can bill a nurse visit because the nurse does the assessment and documents it as such," Bonner says.

 

Unlike other E/M services codes, 99211 has no requirements for history, examination and medical decision-making, Bonner says. "But even if there are no other criteria to go by, at least you have to document an assessment." 

 

The documentation might read: "The patient came in for an allergy injection, sat for 20 minutes, I looked at the site, and there was no reaction." Simply writing "Patient presents for allergy shot" and indicating what was given would not constitute an assessment, Bonner says.
 

Sometimes, the physician examines the child as well. For example, the child may have a cold, and the physician wants to make sure the allergy shot will not cause an adverse reaction. In this case, the physician sees the patient and bills an office visit code. Link the office visit diagnosis to the condition that resulted in the need to see the physician. 

 

If a patient comes in to with a cold or some other problem -- perhaps requesting to see the doctor for a problem even though the appointment is for a shot -- bill an E/M service in addition to the injection.

 

 

Joel F. Bradley, MD, FAAP, a member of the AAP coding and reimbursement committee, recommends attaching modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to any E/M code reported with 95115 or 95117. Under the definition of modifier -25, the office visit must be "significant" and "separately identifiable" from the allergy shots. Based on this requirement, using 99211 with an allergy shot would not seem justifiable.

 

You don't need a separate diagnosis for the 99211, according to CPT, even if you use modifier -25. In addition, CCI does not bundle immunization and other injection codes with nurse visits. 

 

Whether to use modifier -25 depends on the individual payer, Bonner says. There are three choices: (1) The payer bundles 99211 with 95115 and 95117 and requires modifier -25 on the nurse visit, (2) The payer bundles 99211 with 95115 and 95117 and won't pay for the nurse visit whether you use modifier -25 or not, (3) the payer has no edits that bundle 99211 with 95115 and 95117 and you can bill both codes without modifier -25.

 

How should you determine how to bill for allergy shots? Bonner recommends that you tell the insurance company what you're doing -- in writing. "From a compliance perspective, you should write to the insurance company and say, 'Here's how we do it. Is this the appropriate way? Please advise.'" That way, Bonner says, you have protected yourself. The insurance company representatives can't accuse you of going against their billing principles because you have already cleared your coding protocols with them.