Pediatric Coding Alert

Stress patient can't receive shot without pediatrician evaluation

Overturning one carrier's denials for same-day office visits with injection administration hinges on discussing the combination claims with a medical director.

Although the National Correct Coding Initiative (NCCI) version 11.3 bundles antibiotic injection administration (90788, Intramuscular injection of antibiotic [specify]) into a same-day office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...), one payer reimburses the reverse. This insurance company's policy does not allow an E/M service on the same day as 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) or 90788, reports Julie McCuistion, billing administrator at Pediatric Associates of Dallas. "The carrier will pay only one charge."

Problem: Practices may lose around $36, because the insurer pays the lower priced code. The carrier pays the injection administration ($16.67 for 90788 based on the 2005 National Physician Fee Schedule) instead of the office visit ($52.68 for 99213 national rate), says Sharon Maylum, RN, clinical nurse manager at Northwest Dayton Pediatrics in Ohio. Using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service) to indicate the E/M is significant and separately identifiable from the injection administration doesn't solve the problem.

How it works: After performing an E/M service on a child who presents with a high fever, the pediatrician diagnoses the patient with a urinary tract infection and decides to give the individual a Rocephin injection. You submit 90788 and 99213-25 linked to ICD9 599.0 (Urinary tract infection, site not specified), as well as J0696 (Injection, ceftriaxone sodium, per 250 mg). The carrier disallows the E/M service and pays only the injection administration along with the medication.

Take EOB Stack to Rep Meeting

To fight the inappropriate bundle, "make an appoint-ment with the payer's medical director," recommends Victoria S. Jackson, practice management consultant with JCM Inc. in California. Take to the meeting all your denied office visit explanation of benefits (EOBs). "You can make a stronger argument when you address a large number of claims than you can with individual appeals."

Maylum is taking this advice to heart. "We are going to attempt to talk to a representative next week."

Explain E/M Service Is Necessary Before Shot 

Education is the key to getting the carrier to change its policy. "You have to explain that the pediatrician has to evaluate the patient prior to performing the injection," Jackson emphasizes.

Remind the representative that giving Rocephin injections in the office saves the insurer money. Before Rocephin injections were available, these patients would usually require intravenous antibiotics in the hospital, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. "Now, we can give an injec-tion of antibiotic in the office." But the level of risk associated with these cases is still high.

Bottom line: Insurers should pay both the office visit and the injection administration, provided documentation supports the modifier 25-appended E/M code as significant and separate from 90782 or 90788. But at this point, coders, such as Maylum, will be content reversing the inappropriate edit. "We just want carriers to pay the office visit."