Wiki E&m with injection

[carol ann]

Pt arrives and is diagnosed with only bronchitis. The physician determines that the pt needs an antiobiotic. He orders 250 mg j0696 and an injection 96372. I have been told to bill 99213 with 25 modifier with the j code and the injection. We have done this and it is almost always denied or they pay the injection code only and not for the e&m or the medication. Can we bill for the e&m 99213 with the j code only, no modifier, no injection code 96372.

 

[mitchellde]

You should appeal to get paid for both. This is a problem with payers trending based on review. They have reviewed and found that most of the time the documentation does not support the use of the 25 modifierm so they are inclined to pay for one or the other and wait to see your response. So if you can support it then appeal! If you cannot support it then do not bill it in the first place.

 

[eadun2000]

Pt arrives and is diagnosed with only bronchitis. The physician determines that the pt needs an antiobiotic. He orders 250 mg j0696 and an injection 96372. I have been told to bill 99213 with 25 modifier with the j code and the injection. We have done this and it is almost always denied or they pay the injection code only and not for the e&m or the medication. Can we bill for the e&m 99213 with the j code only, no modifier, no injection code 96372.

i am confused... patient comes in because he was sick... determined he has bronchitis and the doctor orders an injection. Why would you even think about not coding for the injection? The patient did not come in for a planned injection, correct? So then why would you just leave off the 96372? Insurance companies are notorious for denying E/M when a procedure is performed... HOWEVER, that is why you appeal. No sense of losing out on money just because an ins co says so... of course they don't want to pay... they want to make a profit.. just keep that in mind. If you can justify the office visit and the procedure then you have no reason to have to lose out on rightful compensation. Hope this makes sense.

 

[eadun2000]

Per our office the injection is bundled with the E&M so it would not be seperately billable

There is absolutely no reason for an injection to be bundled in the E/M unless the patient came in only for the injection, ie already scheduled procedure, in which case you would not code an E/M anyway. Why does your office incorrectly assume that an injection is not going to be paid with a mod 25 on the office visit just because you think it is not separately billable? I cannot even begin to imagine the amount of revenue your physician/s are missing out on... wow.

 

[RebeccaWoodward*]

Per our office the injection is bundled with the E&M so it would not be seperately billable

That is incorrect...

If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to the chemotherapy administration or nonchemotherapy injection and infusion service. For an evaluation and management service provided on the same day, a different diagnosis is not required.

Page 35

http://www.cms.gov/manuals/downloads/clm104c12.pdf