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Pediatric Coding Alert

Use 25 to Overturn Denial of OV With 95115 or 95117

Medicare now allows same-day E/M service and allergy injection -- and your payers should, too Before you write off another E/M service-allergy shot bundle, try these specialty-society-backed tactics.
 
Case study: One pediatric coder requested help for claims involving 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) and 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or CPT 95117 (... two or more injections). Insurance companies are denying the office visit as incidental to the immunotherapy injection, says Tonya Beans, medical biller for Lloyd Charles Jr., MD, a pediatrician in Upper Marlboro, Md.
 
Would a modifier be appropriate in these instances? Here's what allergy coding experts recommend. Step 1: Get Official Modifier Guidance When you report an office visit (OV) and same-day injection, CPT does not require you to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Medicare allows an office visit (OV) and injection on the same day without modifier 25. Pediatricians don't usually deal with Medicare, but most commercial payers are following Medicare's rules.
 
Example: A pediatrician sees a patient due to nasal congestion (478.19), and then the patient receives her scheduled bimonthly series of two allergy injections for allergic rhinitis due to pollen (477.0). The physician performs and documents a level-two E/M service. You may report 99212 and 95117, according to Medicare rules. Step 2: Update Payer on Policy Change Billing 99212 or any other E/M service with 95115 or 95117 is a recent turn of events. Prior to Jan. 1, 2006, Medicare designated allergy injections as global-period codes, says Robert A. Nathan, MD, president of the Joint Council of Allergy, Asthma and Immunology (JCAAI), in a members' letter. The designation meant you could not bill 95115 and 95117 with an E/M service without using modifier 25.
 
New way: Under new Medicare policy, 95115 and 95117 no longer have global periods. Therefore, "you are allowed to bill an E/M service (including 99211, Office or other outpatient visit for the evaluation and management of a patient, that may not require the presence of a physician ...) with allergy injection codes without meeting the requirements for modifier 25," states the JCAAI letter. Because 95115 and 95117 include no payment for physician work, payment of a separate E/M service is appropriate. 
 
Problem: Some commercial carriers haven't gotten the message, says Kathy Anderson, CPC, practice consultant at Allergy Partners PA in Asheville, N.C. In fact, a survey conducted by JCAAI indicates practices across the United States are all having the same issues. Step 3: Opt for 25 When Appropriate Although Medicare policy and CPT guidelines do [...]