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Family Practice Coding Alert


Use Modifier 25 to Obtain Admin Pay With E/M

Question: I noticed that the Medicare Fee Schedule lists an "A" status for the injection G code. Does that mean I may bill an office visit in addition to a B-12 shot administration?

New York Subscriber
Answer: You may report 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) in addition to G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular).

The 2005 National Physician Fee Schedule Relative Value File assigned the new injection G codes an "A" (Active) status. So, Medicare allows separate payment for G0351 even if you bill another physician service that day, such as 99212-99215.

The previous CPT therapeutic injection administration code contained a "T" (Injections) status. That meant Medicare would bundle the old injection code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) into any E/M code you reported on the same day.

Watch out: To report injection administration in addition to an office visit, the family physician must perform and document a significant, separate E/M service from the injection administration (G0351). You will also need to report the office visit with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

You'll need modifier 25 to override the National Correct Coding Initiative version 11.0 edits that make the injection service a component of the E/M code. The edits allow you to append a modifier to break the bundle. Therefore, when documentation supports modifier 25, you may report G0351 in addition to an office visit code.

Exception: The edits do not permit you to use a modifier to override the G0351-99211 bundle. So you may not report this pair, regardless of modifier.

Reminder: Don't forget to code the B-12 supply with J3420 (Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg). Answers to You Be the Coder and Reader Questions provided by Victoria S. Jackson, CEO of Omni Management in Lake Forest, Calif.; Jeffrey Linzer Sr., MD, MICP, FAAP, representative to the ICD-9-CM editorial advisory board; and Belinda M. Robinson, CPC, coding specialist at Valley Health Care in Mill Creek, W.V.

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