David Stern, MD, CPC
Q. Can we bill an evaluation and management code
along with the code for administration of an intravenous
injection?
A. Although it may seem obvious to expect reimbursement
in these situations, Medicare waited until 2006
to begin reimbursing physicians for a separate E/M (99201-
99205, 99212-99215) when performed at the same time as IV
drug administration. The Medicare Claims Processing Manual
states, “Medicare will pay for medically necessary office/outpatient
visits billed on the same day as a drug administration
service with modifier 25 when the modifier indicates that a
separately identifiable evaluation and management (E/M)
service was performed that meets a higher complexity level
of care than a service represented by CPT code 99211….For an
E/M service provided on the same day, a different diagnosis is
not required.”
For example, you should bill an E/M with modifier 25 when
a patient comes in for a migraine headache and the physician
determines that the best treatment is an intravenous injection
of prochlorperazine. Even though there may be only one diagnosis
of migraine headache (ICD-9 = 346.00), it still it is appropriate
to bill both for the therapeutic injection and the physician’s
evaluation of the patient.
The rationale: It’s medically necessary for the provider to
evaluate the patient whether the patient is suffering from a migraine
headache or some other more serious problem (such as
an intracranial hemorrhage, brain tumor, or meningitis).
Q. Don’t I need two separate diagnoses to code for the E/M with modifier 25?
A. A separate diagnosis is not necessary to code for the E/M with modifier 25, according to both Medicare and CPT rules.
Q. Is it appropriate to employ an E/M code for each
and every time the patient visits the urgent care
center and receives an intravenous injection?
A. Not always. Two examples of situations where it would
not be appropriate to code for an E/M:
The patient calls the physician and reports that the migraine
headache has returned and the physician instructs
the patient to come into the urgent care center to receive
another injection of prochlorperazine.
If the patient simply returned, received the medication
from the nurse, and did not see the physician.
Work values now are included in drug administration codes,
so there has to be a truly separate evaluation and management
(not merely an evaluation and management incidental to the
procedure code) to qualify for reimbursement for an E/M code.
Q. Could we code a 99211 (with modifier 25) for the
nursing evaluation? The nurse could document
the patient’s vital signs and a notation that the patient
states that this is a “typical migraine headache.” Would
this suffice to demonstrate a nursing evaluation and
management?
A. Although the documentation noted would be appropriate,
coding a 99211 (with modifier 25) would not be
appropriate. Medicare does not reimburse for this code (99211)
when submitted along with an intravenous injection code.
Prior to 2006, many private payors reimbursed for code 99211when coded on the same day of an injection.
Note: CPT codes, descriptions, and other data only are copyright 2007 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).
Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.
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David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.practicevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at
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