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Family Practice Coding Alert

You Be the Coder:
Allergy Shot With Office Visit

Question: A patient came to our office for a level-three outpatient visit and requested an allergy shot. I billed 99213 (established patient, office or other outpatient visit) with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of other procedure or service) and 95115 (professional services for allergen immunotherapy not including provision of allergenic extracts; single injection). The claim was denied. How do I code this service?

Minnesota Subscriber


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Answer: The scenario is coded correctly and, therefore, the problem does not lie in how the coder reported the encounter with the patient.

To uncover what is going on, the family practices first step should be to investigate why the carrier did not reimburse for the allergy shot. The coder should examine the denial documentation, paying particular attention to the diagnosis code to make sure it demonstrates medical necessity. This is often the reason behind denials. There should be at least two diagnosis codes one attached to the evaluation and management (E/M) service (i.e., 785.1, symptoms involving cardiovascular system; palpitations) and one to the injection (i.e., 477.0, allergic rhinitis; due to pollen).

In other cases, the allergy shot may not be covered by the patients contract. If this is the situation, the family practice should have a waiver form prepared to provide to patients insured by this carrier. Inform the patient that because their insurance does not cover allergy shots under these circumstances, he or she will be liable for the charges. At the same time notify the carrier that, although they do not pay for these services, patients do request shots at the office visit. Inform the payer that you will be billing the patient for these services and collecting payment at the time of treatment, while billing an E/M service separately to the carrier. Ask the insurer for their guidelines, and try to get them to commit their response in writing.