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 still require modifier 25 when the physician provides an E/M on the same day as the injection, says Kathy Anderson, CPC, practice consultant at a physician's office in Asheville, N.C. In fact, a survey conducted by JCAAI indicates that practices across the United States are all having the same issues.

Step 3: Opt for 25 When Appropriate

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

Rest easy: JCAAI 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.

Step 4: Avoid Modifier on Related 99211

You can even report a minimal E/M service related to immunotherapy. Providers may bill for a nurse-only visit (99211) when dealing with clinical issues surrounding allergy injection administration, the JCAAI says. The service could represent the nurse directing a patient on what to do if the patient:

• is ill, or

• has 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 report 99211, because the service is considered part of the injection. But you can bill 99211-25 for providing patient counseling unrelated to the injection--if the nurse documents the medically necessary and separate E/M service that she provided.

Step 5: Resubmit, Appeal, Educate

If payers reject claims for E/M services billed on the same day as an injection, do these three things to try to fix the situation:

• check if the claim included modifier 25
• resubmit with modifier 25 when appropriate
• appeal if you still get a denial upon resubmission--and inform the insurer of the policy allowance.