Pediatric Coding Alert

Question: A pediatrician saw a child with severe bilateral otitis. Because this was her third case of otitis media within the past four months, the doctor gave 500 mg of Rocephin. The child returned for the next two days, each time receiving 500 mg of Rocephin.
 
The original visit contained three lines items: the office visit (99214), the Rocephin (J0696 x 2), and the injection (90772). The insurance company paid only for the injection, denying both the Rocephin and the office visit charge. The evaluation of benefits states, “No additional allowance for an office visit related to procedure.”
 
What did I do wrong?

Illinois Subscriber

Answer: The payer may bundle the office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient) into the injection code (90772, Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) based on software edits.
 
The National Correct Coding Initiative (NCCI) version 13.0 considers office visits 99201-99215 as a component of the injection code 90772. Insurers that follow NCCI may adopt this edit that stems from Medicare, not CPT guidelines.
 
Not all insurers, however, bundle 99201-99215 into 90772. For instance, South Carolina Medicaid allows separate reimbursement for E/M visits and additional office services from injection codes. So it’s worth your while to check the CMS-1500 form that you submitted for a few possible errors.
 
1. Make sure you entered modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) following 99214. CPT 2006 added the stipulation that you need modifier 25 when a physician performs a significant, separately identifiable E/M service in addition to injection administration 90760-90779. (See the introductory notes for Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions [Excludes Chemotherapy].)
 
2. Verify that you linked both 99214-25 and 90772 to the OM diagnosis, such as 381.01, Acute serous otitis media.
 

Tip:  insurer still bundles the E/M service with the administration -- or you initially filed the claim using the above guidelines -- appeal the 99214-25 denial using the CPT language noted above. In your letter, also point out that CPT does not require a different diagnosis for a same-day E/M service.
 
You should, however, demand payment for the two units of J0696 (Injection, ceftriaxone sodium, per 250 mg). In the future, you could have the patient pick up the prescription, which would eliminate your cost in providing the medicine. The nurse could then administer the injection when the patient returns.
 
Because the injection would be at a separate session, you could then append modifier 59 (Distinct procedural service) to 90772. The edits allow a modifier to unbundle 99201-99205 and 99212-99215 from 90772 if circumstances, such as separate sessions, make billing the pair appropriate.