Primary Care Coding Alert

Question: A 75-year-old established Medicare patient with a plan of care in place for her pneumococcal meningitis reports to the FP for a scheduled Rocephin injection. A qualified non-physician practitioner (NPP) injects the patient with 750 mg of Rocephin. After the injection, the patient says "My shoulder really hurts." During a problem focused history and exam, the NPP diagnoses adhesive tendinitis in the patient's right shoulder, and recommends acetaminophen and rest for the injury. Can I report the E/M and the injection?

Wisconsin Subscriber

Answer: You can code for the injection and the E/M in this instance. On the claim, report the following:

• 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for the injection
• J0696 (Injection, ceftriaxone sodium, per 250 mg) x3 for the Rocephin supply
• 320.1 (Bacterial meningitis; pneumococcal meningitis) appended to 96372 and J0696 to represent the patient's condition
• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straight-forward medical decision making ...) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99212 to show that the E/M and the injection were separate services
• 726.0 (Adhesive capsulitis of shoulder) appended to 99212 to represent the patient's shoulder injury.

Remember: The reason that you can code the injection and E/M is that the services were for significant and separately identifiable, which is further supported by the fact that they involved distinct patient issues (meningitis, sore shoulder). Make sure your diagnosis codes line up to the appropriate codes, or you could be facing a denial.

Also, you should not code this encounter as incident-to the physician, as the NPP treated a new problem. In order to report an incident-to service, the NPP must be following a plan of care for a previously diagnosed condition for the service.

-- Information for and answers to You Be the Coder and Reader Questions reviewed by Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians in Leawood, Kan.