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Pam Posted Fri 22nd of September, 2017 13:57:02 PM
Patient comes to office for an annual est. patient physical. While here ask for a tetanus shot. We billed for the phys 99396, Adacel 90715 and inj. 96372. Insurance paid for Adacel and the inj but not the phys. Should we have modified the phys? And if so with what modifer? 25 Is for E&M would that include a phys?
SuperCoder Answered Mon 25th of September, 2017 01:29:48 AM

HELLO

Appropriate codes as per the above scenario would be 99396-25, Adacel 90715, and injection 96372. Physician can bill both E/M with modifier -25 and therapeutic injection code if it meets certain guidelines. If billing for any significant separately identifible E/M with modifier -25 attached, make sure that at least ROS and exam (for established) should be documented and reviewed by the doctor. Without ROS and exam, you never bill separate E/M. As per guidelines, it says "an E/M service for an established visit requires two of three key components: history, examination, and decision-making." Documenting only the evaluation of a separate problem without documenting the management component (what was done about the problem) is incomplete and will result in a denial, with or without the Modifier 25. So if any sign and symptoms related to final dx, should not be reported separate E/M-25.

Please refer this link for appropriate billing with seprate identifiable E/M with therapeutic injection code:
http://www.network-health.org/uploadedFiles/pdfs/payment_policies/pay_policy_modifier_25.pdf

HOPE THIS HELPS!

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