Practice Management Alert

Take a stab at preventing denials with modifier -25

Although Medicare and most other payers bundle injections and office visits, you can sometimes get paid for both if you know how to identify the appropriate situations.
 
Billers often want to report an E/M code along with an injection to account for the time the physician spent with the patient in addition to administering the injection.

But you must remember that reimbursement for injection codes includes compensation for the physician's time spent with the patient. You only deserve additional payment if the physician provides a separately identifiable service as well as the injection.

Example: A new Medicare patient presents to receive a steroid injection for shoulder pain but also has hypertension that requires attention. If the provider documents separate treatment of the patient's hypertension, you should bill for both the injection and for the evaluation of the hypertension, says April Borgstedt, CPC, president of Working for You Consulting in Broken Arrow, Okla.

You code: For the injection, you could report G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) along with the appropriate E/M code, such as 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...).

The key to payment is that you must attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to instruct carriers that it's a separate service, Borgstedt says.

You may have to use CPT's injection code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) if you're billing a private carrier. Remember that Medicare now only accepts the new injection G codes G0351 and G0352.

Check Your E/M Elements - and ICD-9 Codes

Before you separately bill the E/M with modifier -25, be sure the physician performed an exam that will satisfy coding and medical-necessity guidelines, Borgstedt adds. For instance, if the patient is new to your office, your physician's E/M service should meet all three key elements: history, exam and medical decision-making.

Linking the proper ICD-9 codes to the injection code and E/M service will help to prevent denials. Coding guidelines and insurers' policies may not require different diagnoses for the procedure and E/M when you use modifier -25, but doing so increases your chances of getting paid with some carriers, Borgstedt says.

Fraud alert: Because many carriers do require a separate condition or reason for the E/M service, billers may be tempted to arbitrarily choose an ICD-9 code to support the separate E/M charge.

You should never report any code without medical documentation to back it up, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.