Pediatric Coding Alert

Tell payers 'NCCI 11.3 supports 90788 as separately payable from E/M service'

CMS’ latest round of edits gives you new evidence in your battle to secure office visit payment in addition to injection administration.

The National Correct Coding Initiative (NCCI) version 11.3, effective Oct. 1, bundles office visit codes ( CPT 99201 - 99215 , Office or other outpatient visit for the evaluation and management of a new or established patient …) with injection administration code:

• 90788--Intramuscular injection of antibiotic (specify).

When appropriate, you may break the E/M service-injection edit with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service). The edits allow a modifier to bypass all 99201-99215 and 90788 bundles, except for claims containing 99211 (... may not require the presence of a physician).

Key: To charge 99201-99205 or 99212-99215 in addition to 90788, the visit must be significant and separate from the injection administration. “Using modifier 25 when reporting an office visit and injection administration makes sense,” says Candy Rogers, billing manager at Pediatric Primary Care in Richmond, Va. Appending modifier 25 to the E/M code indicates the service’s significant, separately identifiable nature.

Some insurers already require modifier 25 when you report an office visit with an antibiotic injection. For instance: Cigna of Tennessee allows 90788 with 99201-99205 or 99212-99215. Practices may bill office visits “as a drug administration service with modifier 25 [attached to the associated E/M code] indicating that a separately identifiable evaluation and management service was provided,” states the carrier’s February 2004 newsletter.

Point Out 90788’s Revised Status

Many coders, however, are surprised to hear that Medicare permits an E/M service on the same day as a drug administration. Payers may still have bundles in effect based on outdated fee schedule information.

The 2005 National Physician Fee Schedule changed the status indicator for 90788 from “T” (Injections) to “A” (Active). The new designation means Medicare will pay separately for injection services even if you bill another physician service that day, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa. “Previously, the administration codes had a ‘T’ status, which meant you were not allowed to bill 90788 in addition to an E/M service.”

Good idea: Inform major insurers of 90788’s revised designation. If the company bases payment policies on the National Physician Fee Schedule, it should also adopt this change.

Stress E/M Service’s Separate Nature

For insurers that continue to deny the E/M code, speak with a medical director, encourages Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric and Adolescent Medicine PA in Medford, N.J. Emphasize that prior to giving a child an antibiotic shot, a pediatrician must “evaluate the ill child, determine what is wrong and make therapeutic recommendations over and above the actual medicine injection.”

The E/M service’s key components lead the physician to decide the child requires an antibiotic injection and makes it significantly and separately identifiable from the procedure. Therefore, “payers should pay both the office visit and the injection administration,” Scott stresses.

Because the edits reinforce the E/M’s separately billable nature, the edits come as great news to Lisa Marie Barnes, CPC, coding specialist at Fayetteville Diagnostic Clinic in Arkansas. Insurance companies “should have been covering injection administration all along,” she says.

Research Insurers’ Policies

Coders also welcome the modifier clarification that the edits provide. “CPT’s medicine section is very vague on using modifier 25,” says Carol Hall, CPC, a coding and reimbursement specialist in San Diego.

Although CPT’s “Vaccine/Toxoids” subsection offers modifier guidance, the AMA is silent about reporting E/M services with therapeutic or diagnostic infusions. “Significant, separately identifiable E/M services should also be reported,” states the AMA in the “Vaccine/Toxoids” subsection introductory notes. CPT’s “Thera-peutic or Diagnostic Infusions (Excludes Chemotherapy)” subsection notes do not address the topic.

On 90788-office visit claims, “I don’t think the E/M code should require modifier 25,” Scott says. But if an insurer rejects the injection administration, you should resubmit the claim using modifier 25.

Time saver: Make a list of each insurer’s requirement. “Some of our commercial carriers have been covering 90788 and an E/M service without using modifier 25,” Barnes says. “Medicare now reimburses the injection service with modifier 25 on the E/M service.”

Expect more insurance companies to bundle office visit codes lacking modifier 25 into 90788. Even though Medicare issues the NCCI edits, “the policies usually trickle down to private payers,” Rogers notes.