Wiki Mod 25 questions

[mlowery31]

This is coming up a lot in my family practice office. Say the patient comes in for allergies, they get an allergy shot while here (Depo Medrol). Is it appropriate to use a modifier 25? I feel like the provider should get credit for the E/M, he has to decide to do an allergy injection via his exam. Same thing happens with a trigger point injection or arthrocentesis. Sometimes those decisions are made after the exam on the same day.
I'm just wondering what is appropriate in this situation? Any advice would be appreciated.

 

[AprilSueMadison]

These are a little old, but provides good information which can be backed up by further research of CMS mod 25/allergy shot guidelines.
https://www.aap.org/en-us/Documents/coding_aap_position_paper_99211_ia_2016.pdf
https://www.aaaai.org/Aaaai/media/M...ts/Practice Resources/Modifier-25-Article.pdf

An E/M with modifier 25 should be applied only when a significant and separately identifiable service is administered. If a patient presents with a cough due to allergies, or other allergy symptoms, and the patient receives a workup due to that and the provider decides that a shot of Depo Medrol is required to help the patient leave the office without sneezing 70 times, then I would expect (as long as the documentation supports it) billing to occur with an E/M-25, injection and drug code.

If a patient presents for a pre-scheduled allergy shot for immunotherapy, I would not expect an office visit to be billed each time and if so, it would raise a red flag.

I cannot speak to the other injections with certainty, but to use modifier 25 on an office visit there always has to be a significant and separately identifiable service. That doesn't change just because it is an injection over something more clear like a biopsy.