Pediatric Coding Alert

Question: A payer denied our claim for an established patient office visit in addition to CPT 96372. We appended modifier 25 and appealed, but were denied again. What are we doing wrong?

South Dakota Subscriber

Answer: If you're billing a payer that follows the Correct Coding Initiative (CCI), the edits bundle office visit codes 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) into therapeutic injection code 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular).

Good news: You are allowed to override the edit with a modifier, such as modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) as you did. Make sure your documentation supports the office visit as significant and separately identifiable from the minor E/M associated with the procedure code 96372.

Caution: The edit, however, does not allow you to report 99211 with 96372 under any circumstances. Medicare considers the 99211 nurse service part of the relative value units included in 96372. Private payers that follow the resource based relative value system (RBRVS) shown in Medicare's Physician Fee Schedule may similarly bundle 99211 into 96372 and not allow you to separately report a nurse service.