Primary Care Coding Alert

When the FP performs allergy injections, coders typically consider any E/M the FP or nurse provides as inherent to the injection. On the other hand, a leading allergy council recommends checking for evidence of a separate E/M service and coding for it, when appropriate.

Before you write off another E/M service-allergy shot bundle, try these specialty-society-backed tactics.

Case study: One coder requested help for claims involving 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) and 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or CPT 95117 (... two or more injections).

Insurance companies are denying the office visit as incidental to the immunotherapy injection, says Tonya Beans, medical biller for Lloyd Charles Jr., MD, in Upper Marlboro, Md. Would a modifier be appropriate in these instances? Here's what allergy coding experts recommend.

When you report an office visit (OV) and same-day injection, CPT does not require you to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). However, language added to the allergy and clinical immunology guidelines in CPT 2008 clearly recommends that you use modifier 25.

CPT's new language states: "Do not report Evaluation and Management (E/M) services for test interpretation and report. If a significant, separately identifiable E/M service is performed, the appropriate E/M service code should be reported using modifier 25."

Medicare allows an OV and injection on the same day without modifier 25. FP's won't always deal with Medicare, but most commercial payers are following Medicare's rules.

Example: An FP sees a patient due to nasal congestion (478.19), and then the patient receives her scheduled bimonthly series of two allergy injections for allergic rhinitis due to pollen (477.0). The physician performs and documents a level-two E/M service. You may report 99212 and 95117, according to Medicare rules.

Billing 99212 or any other E/M service with 95115 or 95117 is a recent turn of events. Prior to Jan. 1, 2006, Medicare designated allergy injections as global-period codes, says Robert A. Nathan, MD, president of the Joint Council of Allergy, Asthma and Immunology (JCAAI), in a members- letter. The designation meant you could not bill 95115 and 95117 with an E/M service without using modifier 25.

New way: Under new Medicare policy, 95115 and 95117 no longer have global periods. Therefore, "you are allowed to bill an E/M service (including 99211, Office or other outpatient visit for the evaluation and management of a patient, that may not require the presence of a physician -) with allergy injection codes without meeting the requirements for modifier 25," states the JCAAI letter. Because 95115 and 95117 include no payment for physician work, payment of a separate E/M service with these codes is appropriate.-

Problem: Some commercial carriers haven't gotten the message, says Kathy Anderson, CPC, practice consultant in Asheville, N.C. In fact, a survey conducted by JCAAI indicates practices across the United States are all having the same issues.

Although Medicare policy and CPT guidelines do not require modifier 25 on claims for higher-level E/M services and allergy injections, payers may have system edits in place that make using the modifier necessary, consistent with the CPT guidance noted above.

"We usually add modifier 25 to the E/M and have no problems getting paid," Anderson says.

Rest easy: The allergy specialty society backs resorting to modifier 25 in these situations. If you think an encounter meets the criteria for modifier 25 (for instance, the physician has provided a separately identifiable service distinct from the injection), consider resubmitting rejected claims with modifier 25, the JCAAI says.

Example: Higher-level office visits not related to the injection administration would probably qualify for modifier 25, the council says.

But "make sure you have appropriate documentation," the JCAAI says.

You can even report a minimal E/M service related to immunotherapy. Providers may bill for a nurse-only 99211 when dealing with clinical issues surrounding allergy injection administration, the JCAAI says.

The service could represent directing a nurse who gives injections on what to do if a patient:
- was ill
- missed an injection
- had a large, local reaction or mild unreported systemic symptoms after his last injection.

Be careful: On claims involving a nurse visit related to allergy immunotherapy, don't append modifier 25 to 99211. When you bill 99211 for providing clinical advice related to the injection, modifier 25 is unnecessary and does not apply, the JCAAI says.

But the nurse must document the medically necessary E/M service that she provided.