Pediatric Coding Alert

Question: We have a patient who reports for immunotherapy injections for a peanut allergy. Typically, our physician assistant (PA) performs a single allergy injection, then monitors the patient for 13 minutes after the shot. Can I separately report evaluation and management (E/M) service 99212 in addition to 95115, using time to select the E/M level for this post-injection monitoring?

Illinois Subscriber

Answer: In this scenario, you should not report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter) in addition to 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection).

Why? Post-procedure patient monitoring should be considered part of the 95115 service in this encounter. Even though the post-injection monitoring fits the time parameters for 99212, and even though CPT^® guidelines for the allergen and clinical immunology codes (95004-95199) tell you that “if a significant, separately identifiable E/M service is performed, the appropriate E/M service code should be reported using modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service],” if all your provider does in the encounter is administer the shot and monitor the patient, then your provider has not performed a separately identifiable E/M service, and you cannot bill for the 99212.