Thursday, 16 March 2017

Therapeutic Injection Codes

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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