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Otolaryngology Coding Alert

Educate Payers on CMS' New Same-Day E/M-Shot Policy

These ready-to-go appeals letters will help you get your office visits paid

Combat denials for office visits with same-day immunotherapy injections. Payers may not be aware of the 2006 policy change that now allows separate payment for the E/M service. Prod insurers to align their system with Medicare, CPT and specialty-society coding guidelines by submitting one of the following educational appeal letters (just fill in the details).

For more details on reporting 99201-99215 (Office or other outpatient visit -) in addition to 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95117 (- two or more injections), see -Use 25 to Overturn Denial of OV With 95115 or 95117-. Appeal for Higher-Level E/M Service Denial With Immunotherapy Injection Dear Insurer Representative: You have denied a charge for a higher-level office visit (99xxx) on the same day as immunotherapy injection administration (9511x). Although Medicare previously assigned global days to 95115 and 95117, as of Jan. 1, 2006, the codes no longer contain global days. This means -you are allowed to bill an E/M service (including 99211) with allergy injection codes without meeting the requirements for modifier 25,- according to the Joint Council of Allergy, Asthma and Immunology (JCAAI). Although this change technically only applies to Medicare, most commercial payers follow Medicare policy in this area. Please remove this edit from your coding system and make payment for the E/M service.

In case your system requires modifier 25 in these situations, I have also resubmitted the claim using modifier 25. Documentation is on file that shows the E/M service as significant, separately identifiable from the injection administration. Appeal for Minimal E/M Service Denial With Immunotherapy Injection Dear Insurer Representative: You have denied a charge for a minimal office visit (99211) on the same day as immunotherapy injection administration (9511x). Although Medicare previously assigned global days to 95115 and 95117, as of Jan. 1, 2006, the codes no longer contain global days. This means -you are allowed to bill an E/M service (including 99211) with allergy injection codes without meeting the requirements for modifier 25,- according to the Joint Council of Allergy, Asthma and Immunology (JCAAI). Although this change technically only applies to Medicare, most commercial payers follow Medicare policy in this area. Please remove this edit from your coding system and make payment for the E/M service.

Physicians may bill 99211 when dealing with clinical issues surrounding allergy injection administration, the JCAAI indicates. Because 95115 and 95117 include no payment for provider work, payment of a separate E/M service is appropriate. The service could represent directing a nurse giving injections on what to do if a patient:

- was ill
- missed an injection
- had a large, local reaction or mild unreported [...]


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