Primary Care Coding Alert

Office visits for injections often lead to situations where the family physician performs an E/M service in addition to the injection. In these situations, coding for the appropriate E/M service together with CPT 96372 and the drug code is appropriate and will guarantee increased revenues for your doctor.

When coding for injections, always check if the procedure was the reason for the office visit or was part of the doctor's management of the patient. If a patient sees the family physician for a medical problem and the doctor notes the need for drug injection, then an E/M service can be billed for this aside from the injection code. According to Martha Conradson, an administrator for Desert Bloom Family Medicine in Phoenix, as long as the injection was not a planned event, then you can bill for the E/M service with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Example: An established patient with history of fever, cough, and productive sputum is diagnosed with bronchitis by the FP. Rocephin 1 gram was administered by the doctor. The doctor spent a quarter of an hour with the patient. After proper documentation of a level three office visit, the following codes will apply:

• 99213-25 -- Office or other outpatient visit ...Physicians typically spend 15 minutes face-to-face with the patient and/or family

• J0696 -- Injection, ceftriaxone sodium, per 250 mg (4 units)

• 96372 -- Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

• 466.0 -- Acute bronchitis (this serves as the primary diagnosis).

If a patient sees the FP for a given medical condition and receives an injection of a drug he routinely is given for another condition, then you can also code for this separately. Modifier 25 will still be used as these will be for two distinct and separate reasons/diagnoses, explains Sharon Knutson-Holmes, CPC-H, CPAT, CCA, who is a compliance auditor for Springfield Clinic in Springfield, Ill.

Example: A patient schedules an appointment to see her FP because she is having recurrent headaches and visual disturbances for the past two weeks. She regularly receives B12 injections for B-12 deficiency, and is due for her next one of these as well, so the physician goes ahead and administers this at the same visit. Charge as follows:

• 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 25 (level depends on history, exam, and medical decision making)

• 96372

• J3420 (Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg)

• link 9921x-25 to diagnosis of 784.0 (Headache)

• list 368.9 (Unspecified visual disturbance) as a secondary diagnosis for 9921x-25 for visual disturbance reported by patient if exam did not reveal any cause and no tests were ordered that confirmed any definitive cause, but do not link more than one diagnosis per procedure per CMS-1500 billing guidelines.

• link 96372 and J3420 to 266.2 (Other B-complex deficiencies) for B12 deficiency.