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Primary Care Coding Alert

Reader Questions:

Separate Dx Keys This E/M-Injection Combo

Published on Fri Mar 26, 2010

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 [...]
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