READER QUESTIONS:
Appeal Same-Day Drug Admin Denials
Published on Sun Sep 09, 2007
Question: We are having problems getting office visit codes paid with therapeutic/diagnostic injections, plus the substance injected. For instance, the physician saw a patient for contraceptive surveillance. We billed 99213 (office visit), 90772 (injection administration), and J1055 (Depo-Provera supply). Cigna denied the claim because -the procedure 99213 is not recommended for separate reimbursement when submitted with procedure 90772.- We have tried to appeal this claim with modifier 25 attached to 99213, but to no avail. What are we doing wrong?
Colorado Subscriber
Answer: Unfortunately, you may not get paid for the office visit and drug administration if your physician's documentation doesn't support separately identifiable services.
How it should work: There is a Correct Coding Initiative edit between 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) and 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician -), which means you cannot report the two code together. That edit doesn't extend to 99212-99215, however. So, you should be able to separately report the office visit and the drug administration if you append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code when your physician provides a significant, separately identifiable problem-related service in addition to the drug administration.
The catch: The denial you-re receiving is either a carrier-specific bundle or it's generated because your E/M documentation and/or diagnosis coding doesn't support the separately identifiable service.
For example, with your Depo shot scenario, you-re saying that the reason for the office visit is contraceptive management. There's a good chance that because there's no separate diagnosis, Cigna is assuming the office visit and Depo administration are not significant, separately identifiable services, even though you-re using modifier 25.
Best bet: Try to appeal, stressing that there doesn't have to be a separate diagnosis to use modifier 25, as long as your physician's service is medically necessary and the documentation supports the modifier 25 use by showing a significant, separately identifiable service.
