Pediatric Coding Alert

Most pediatricians want to see these patients, making 99212-99215 appropriate

Because infants who require Synagis injections are high-risk patients, you will usually bill a physician E/M service in addition to injection administration.

Realize Edits Disallow 99211 With 90772

 You may have overlooked a National Correct Coding Initiative edit implemented for the 2006-introduced code for a Synagis injection: 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). Chapter XI of the NCCI 11.3 edits states, "99211 and 90772 are not reportable together," says Kathy Schnaidt, CPC, at Fort Collins Youth Clinic in Colorado. According to the Medicare file on pages 2 and 3, 90772 has been valued to include the work and practice expense of 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician ...).

Not all payers, however, follow this edit. For instance, the Georgia Chapter of the American Academy of Pediatrics lists coverage policies of various Medicaid CMO policies including Amerigroup, which allows billing 99211 and 90772.

Technically, code 90772 does not include an E/M service. If the E/M service is billed separately, it should include documented E/M components including an interval history and assessment.

Adherence to the edit depends on whom you ask. For compliance reasons, some coders prefer to adopt a uniform, across-the-board approach and follow the NCCI edit standard, regardless of payer. Other coders advocate a per-payer-based coding system. Choose the method that your office feels comfortable with and is feasible based on staff numbers and time.

Bill MD Visits + Immunoglobulin Injection

Encounters involving a Synagis injection, however, often involve a pediatrician-performed E/M service. "Most of the patients who receive Synagis are preemies with growth and development problems," says Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric and Adolescent Medicine in Medford, N.J. "For that reason, I follow their medical conditions as well as the social items with the family (how is Mom doing, how about Dad, etc.) monthly."

Good news: The 90772 edit doesn't extend to other office/outpatient E/M codes (99212-99215). Codes 99212-99215 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) are separately reportable from 90772 if the physician provides a significant and separately identifiable problem-related service in addition to the immunoglobulin injection, Schnaidt says.

Real-world coding: Scott usually codes an office visit that also involves a Synagis injection 99213-25 (at a minimum) with V20.2 (Health supervision of infant or child; routine infant or child health check). "We allocate 30-40 minutes total instead of the usual 15-minute well-check," he says.

Some payers may, however, bundle the injection with the office visit. For instance, Georgia Medicaid CMO considers the "office visit" administration fee bundled. But Well Care permits 992xx (code the correct level visit as appropriate) and 90772.

Don't forget: If your office provides the Synagis, report 90378 (Respiratory syncytial virus immune globulin [RSV-IgIM], for intramuscular use, 50 mg, each) and V04.82 (Need for prophylactic vaccination and inoculation against certain viral diseases; respiratory syncytial virus [RSV]).