Pulmonology Coding Alert

Medicare now allows same-day E/M service and allergy injection

Before you write off another E/M service-allergy shot bundle, try these expert-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; and 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 coding experts recommend. Step 1: Get Official Modifier Guidance When you report an office visit 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). Medicare allows an office visit (OV) and injection on the same day with modifier 25, as long as the visit is separately identifiable from the injection service.

Example: A physician sees an established patient for nasal congestion (478.19) and prescribes a prescription nasal spray, 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 99212-25 and 95117, according to Medicare rules. Step 2: Update Payer on Policy Change Billing 99212 or any other E/M service with 95115 or 95117 is a recent turn of events. Prior to Jan. 1, 2006, Medicare put a global period on allergy injections, says Robert A. Nathan, MD, president of the Joint Council of Allergy, Asthma and Immunology (JCAAI). According to the Medicare Claims Processing Manual, the designation required modifier 25 when submitting a bill for 95115 or 95117 and an E/M service in the same day.

Under current Medicare policy, 95115 and 95117 no longer have global periods. Because 95115 and 95117 include no payment for physician work, payment of a separate E/M service is appropriate.

You may only report and receive payment for the visit when the physician provides a separate, medically necessary E/M service. According to the current guidance in the Medicare Claims Processing Manual, modifier 25 should still be appended to the E/M.

Remember: You cannot report an E/M, even 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician), for provision of the injection only. 

Problem: Despite CPT's policy, some commercial carriers [...]