Our Medicare carrier will not pay for an E&M with code 96372. This is the example and rationale that they gave. Hope this helps.
Q. Could a significant and separately identifiable Evaluation & Management (E&M) be billed if a patient presents with a cough and fever, then the doctor examines the patient and orders labs and x-rays, patient is diagnosed with pneumonia and a shot of Rocephin is ordered? If all elements of a level 99213 are documented by the doctor, would we be able to charge a 99213 with the 25 modifier and 96372/J0696 for this visit with diagnoses code of 486? We are uncertain what “significant and separately identifiable” entails since the injection administration is a result of his decision making.
A. In the IOM, Medicare Claims Processing Manual, Publication 100-04, Chapter 17, Section 20.5.7, states “injection services… included in the MPFS are not paid for separately if the physician is paid for any other fee schedule service furnished at the same time.” Therefore, you would be able to successfully bill the 99213 for the E&M, and the J0696 code for the drug.