Practice Management Alert

If the denials are unfounded, you should fight back

If your practice administers injections, you need to know when - and when not - to appeal a denial for an injection and a separate E/M service on the same day. Check out these real-life billing scenarios:
 
Problem #1: We've always billed for an E/M visit and a joint injection on the same day and gotten paid with no problems. Suddenly some of our carriers started saying they wouldn't pay for both codes on the same day.
 
Problem #2: Sometimes a patient comes into our office specifically for a B12 injection - and in those instances we report only 90782 for the injection and J3420 for the drug. However, other times a provider will render a separate E/M service first and then administer the B12 injection. These claims are denied every time.
 
Think about how you would solve these billing problems, then read the answer  below.

 
Solution: Knowing the details of how to bill for joint injections and B12 shots is the only way to avoid denials - or fight them once they occur. Problem #1 - Joint injections Many orthopedists have recently complained that payers have simply decided to stop paying for medically necessary E/M services on the same day as joint injections, such as knee joint injections.
 
Example: A patient visits a physician who diagnoses the patient's joint pain as arthritis. The physician then performs a joint injection, such as 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). If the physician performed a separately identifiable E/M when he examined the patient to determine the cause of the joint pain and the need for the injection, the physician should be able to bill for both the E/M and the injection, says consultant Ryan Price with Aviacode in Salt Lake City. 
 
Careful: If the patient is scheduled to come in for an injection in advance and there's no reason to perform a separate exam, you shouldn't bill for an E/M visit, says Mary Brown, a coder with OrthoWest in Omaha, Neb.
 
But if it's a new problem or if the established patient has new complaints, then there is medical necessity for the physician to perform an E/M service to determine the need for the injection - and bill for it. Still, "some companies won't pay for it no matter what," Brown says. She recommends appealing the denial regardless. Problem #2 - B12 Injections Most Medicare carriers accept 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for the B12 administration and J3420 (Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg) for the supply of the drug.
 
Downside: Nearly all Medicare and private carriers refuse to [...]