SuperCoder Posted Thu 16th of February, 2017 11:56:21 AM
If a patient comes in for a sore throat and is tested and diagnosed with strep and is given a shot of rocephin, would we bill the E/M with modifier 25, 96372 and the J code for the injection? I have been given conflicting answers by two different consultants. One says not to bill the 96372 unless it is not directly related to the E/M. The other says to bill the 96372 and fight with the insurance company for payment if they don't pay it.
SuperCoder Answered Fri 17th of February, 2017 09:11:28 AM
When you have performed the procedure except the E/M then you can bill that procedure without fear of denial. The insurance will surely pay if the procedure is medical necessity of the patient. So bill E/M and CPT 96372 and J code for supply. Now the thing is, should we append modifier with E/M or not? When you perform the procedure and that is significant, separately identifiable E/M service then you can append modifier 25 with E/M code. In your case, as per CCI edits rules, CPT 96372 is showing that office visit code is a column 2 code for 96372, modifier 25 is allowed in order to differentiate between the services provided. So, use modifier 25 with E/M code.