We are having problems with Humana denying the office visit (w/ Mod 25) when billed with an injection admin code (96372). They are saying that refilling meds doesnt meet the requirements for separate and distinct service, however, that requires separate medical decision making so I feel that it should meet criteria? Am I correct or are they? Where could I find a "documented" answer to this? Thanks in advance!!
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Documentation requirements for 99213-25 with 96372
- Thread starter kellielafferty72@gmail.com
- Start date
ashae17
Guest
If I'm understanding the situation correctly, they are denying the office visit as inclusive to the administration of the injection. If the patient's injection was scheduled previously, the patient comes in for the injection, and after evaluation there are no new complaints, no change in the course of treatment (change in dosage, different medication, etc), and the patient proceeds with the scheduled injection then it is considered inclusive.
Anything regarding the patient's plan of care that is not new and does not require medical decision making beyond that of which has already been done won't be counted as a separately identifiable E/M service.
Anything regarding the patient's plan of care that is not new and does not require medical decision making beyond that of which has already been done won't be counted as a separately identifiable E/M service.
RABBIT2020
Networker
This is an interesting situation.
I have seen in this instance where coders bill/code the office visit and the injection on separate claim forms.
Also, when there is an evaluation and management service and blood is drawn both the E/M and the blood draw 36415 are billed although the blood is ordered based on the E/M service. In addition, when the blood result is reviewed on another date another E/M visit is bill/coded.
is this all over billing?
I have seen in this instance where coders bill/code the office visit and the injection on separate claim forms.
Also, when there is an evaluation and management service and blood is drawn both the E/M and the blood draw 36415 are billed although the blood is ordered based on the E/M service. In addition, when the blood result is reviewed on another date another E/M visit is bill/coded.
is this all over billing?
SharonCollachi
Guest
We stopped doing injections on the same day as an office visit for this very reason, EXCEPT 96372 (a "pain shot" in our office). Our patients are pain patients that are seen monthly. There is more than just "refilling meds." If the doctor's exam causes them to have a pain exacerbation, they may need a shot. We haven't had any issues getting 96372 paid; having said that, we have very few Humana patients and it's possible that none of them have had same-day injections.
lburns23
Guest
I work in a pain management clinic as well, and I have had denials for E&M bundled into the Toradol shot (96372) but I always just submit the records for them and they are reprocessed and paid. I've never had them uphold their denial, but when the providers are reviewing and prescribing other medications, those are a separate service. Sometimes we have someone come in just for the Toradol injection and I do not bill an office visit since there's nothing beyond the injection.
I think that sending records to support the separate charges ought to do it. It's unfortunate that Availity doesn't make that easier!
I think that sending records to support the separate charges ought to do it. It's unfortunate that Availity doesn't make that easier!