Bernadette Posted Wed 07th of August, 2013 18:06:10 PM
One of our doctors, who is a pediatrician, saw a patient who came in for their wellness visit. At this visit, we did administer a Synagis injection. We billed a CPT code
96372 for the injection with a
V05.9 diagnosis code. We also billed the E/M CPT code
99392and CPT codes
99051 under diagnosis code
V20.2. The insurnace denied payment to
96372 stating it was not payable when performed with a related procedure on same date of service. What do we do to get the
96372 paid? We thank you for your response.
SuperCoder Answered Thu 08th of August, 2013 05:24:17 AM
Synagis is a monoclonal antibody. It is used to prevent viral respiratory tract infections (due to respiratory syncytial virus or RSV) in infants and young children at risk for infection. Synagis works by preventing the growth of RSV.
Ask the payor what codes they expect for such patients. Some codes you might consider are V04.82 (Need for prophylactic vaccination and inoculation against Respiratory syncytial virus [RSV]) and V07.2 (Prophylactic immunotherapy).
Code V58.69 is actually a status code indicating that the patient uses a high-risk drug, not that you are providing any care. This code is a secondary code only and not your best choice in this case because there are more specific codes you can use.
You may perform a well child visit that doesn't require vaccine administration, but does require other injections. In these cases, you should still report the injection code with the preventive medicine visit.
For example: Your nurse administers a Synagis injection to a premature baby during a well child visit. In this situation, you'll report the appropriate preventive medicine code with modifier 25 appended, along with 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) to complete the claim.
Link your Synagis diagnosis to 765.10 (Prematurity), and link the preventive visit code to V20.2.
Don't forget: If you are paying for the Synagis, you should also bill for the product. Report 90378 (Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each).
Bernadette Posted Thu 08th of August, 2013 14:58:06 PM
Thank you. Just to be clear, we would bill a
99392-25 with diagnosis
V20.2 and bill
765.10 diagnosis with
96372.. is that correct? Is
765.10 age appropriate if patient is 18 mos. old?
SuperCoder Answered Fri 09th of August, 2013 01:32:50 AM
Good question because I believe the 765.10 was just used for example rather than your case where the child is 18 months. Best bet is to check payer policy and compare it to your documentation.
E.g., This UHC policy discusses certain lung diseases, congenital diseases, and immunodeficiencies in patients under 24 months, but other payers may not agree: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Drug%20Policies/Synagis_policy.pdf
Here’s an Aetna policy also discussing patients under 2 years: http://www.aetna.com/cpb/medical/data/300_399/0318.html.
So you can connect the ICD-9 for the reason the patient requires the Synagis at 18 months (such as chronic lung disease) and V04.82 to the injection code and 90378. And then the 99392-25 with V20.2.