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E/M 99211 with injection codes

Lindsay Posted Tue 18th of February, 2014 11:17:55 AM

If a patient comes in to clinic and only receives an injection along with having vitals taken, Is it appropriate to charge BOTH CPT 99211 and 96372 or 90471 on the HOSPITAL side? I am questioning whether only the administration code should be billed in these circumstances due to the lack of detailed documentation of a clinic visit.

Also, I noticed there are CCI edits (Column 2 codes are components of the comprehensive column 1 codes)in place for these situations. It says Modifier 25 is permitted on 99211 if appropriate. According to the definition of Modifier 25, I dont believe it is warranted. Please let me know your thoughts.

MODIFIER 25:
Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

SuperCoder Answered Tue 18th of February, 2014 15:51:11 PM

You cannot ever bill 99211 with 96372. You have two options:

Option 1: You bill 96372 for the injection if a supervising provider is present in the office.

Option 2: You bill 99211 instead if no supervising provider is present in the office. You should interpret "supervising provider" to mean any qualified supervising care giver who can bill in their own right. This rule would only apply when a registered nurse (RN) is giving the injection, not the ENT, nurse practitioner (NP), or physician assistant (PA).

Heads up: You will also incur another problem if the RN gives the injection and you have no one who can supervise or is qualified to supervise if something goes wrong (called malpractice risk). And if this patient was a Medicare patient and you have no supervision, you should count this visit as a nonbillable event.

Lindsay Posted Tue 18th of February, 2014 16:32:40 PM

Just to clarify, this is an Outpatient clinic in a hospital billing the facility charge. This is not physician billing. Would that make a difference? I thought it would be ok to bill an injection and E/M on the hospital side as long as there was a true clinic visit with other reasons to be there besides getting an injection.

SuperCoder Answered Wed 19th of February, 2014 18:59:07 PM

If the payer is Medicare or any other payer that follows the National Correct Coding Initiative (NCCI) edits, reporting 96372 and 99211 for the same patient on the same date of service will result in denial of the 99211. NCCI designates 99211 as a column 2 code for 96372 and does not permit a modifier to override the edit. Since the Medicare payment allowance for 96372 is higher than that for 99211 anyway, you are best served to report the 96372 code rather than 99211, if forced to choose between the two due to NCCI.

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