Therapeutic injections
may be charged in addition to the medication code.
Therapeutic injection codes also can be billed in
addition to an E/M code as long as it is a physician
encounter, not a nursing encounter (99211). The
appropriate codesfortherapeutic injections are 96372
for therapeutic services, 90471 for immunizations
or G00008 for Medicare plus the medication codes.
Xolair®
(omalizumab) may be charged by using either
96372 or 96401, depending on your payer’s/carrier’s
guidelines. CPT instructs the coder to use 96401
for monoclonal antibody agents and other biologic
response modifiers. The subsection directions also
indicate that it is only for “certain” monoclonal
antibody agents. The subsection directions further
clarify that the service should require physician work
and/or clinical staff monitoring well beyond that of
a therapeutic drug agent, because the incidence of
severe adverse patient reactions is typically greater.
Other carriers may have specific guidelines in their
billing manuals.
CPT (Level I HCPCS) Modifiers and Their
Appropriate Use
A CPT modifier is a two-digit number used to
communicate that the description of the code may
be changed, the circumstances for the patient may
have changed, multiple services were provided at
different times, or for different indications on the
same calendar day.
The most common CPT modifiers to be used in an
allergist’s office:
Modifier 25 – Significant, separately identifiable
evaluation and management service by the same
physician or other qualified healthcare professional
on the same day of the procedure of other services.
The definition of significant and separate identifiable
evaluation and management services implies the
service is provided beyond the usual pre- or post-services of care associated with the therapeutic
or diagnostic procedure performed on the same
calendar day. It is defined and substantiated with
appropriate documentation to support the “on
and beyond” component of the evaluation and
management service. It may be prompted by the
symptoms or conditions but does not require a
separate diagnosis code. It does help, however, to
substantiate the service as separate and identifiable
if the evaluation and management code has a
different diagnosis from the one for the therapeutic
or diagnostic services provided on the same calendar
day. This may be indicated by linking the diagnosis
specific to each service as different primary
diagnoses. With many third party payers having
bundling guidelines, which are a requirement the
allergist follows, the unbundling of services becomes
more of a challenge. In many instances it is necessary
to use the modifier 25 to indicate the evaluation and
management code was provided for assessment of
multiple complaints along with the allergy testing of
the patient on the same calendar date. If the patient is
being provided the assessment only to enable allergy
testing, then it would not be appropriate to bill for
both the evaluation and management service and the
testing on the same calendar day.
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