CODING Q&A Injection Procedures and E/M Codes ■ DAVID STERN, MD, CPC Q . Can we bill an evaluation and management code along with the code for administration of an in- travenous injection? Although it may seem obvious to expect reimburse- ment 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/out- patient 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 diag- nosis of migraine headache (ICD-9 = 346.00), it still it is appro- priate to bill both for the therapeutic injection and the physi- cian’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 mi- graine headache or some other more serious problem (such as an intracranial hemorrhage, brain tumor, or meningitis). A. Q . Don’t I need two separate diagnoses to code for the E/M with modifier 25? 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.prac- ticevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at dstern@practicevelocity.com. w w w. j u c m . c o m 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? Not always. Two examples of situations where it would not be appropriate to code for an E/M: Ⅲ The patient calls the physician and reports that the mi- graine headache has returned and the physician instructs the patient to come into the urgent care center to re- ceive another injection of prochlorperazine. Ⅲ 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. A. 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? Although the documentation noted would be appro- priate, 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 99211 when coded on the same day of an injection. A. Note: CPT codes, descriptions, and other data only are copyright 2007 American Med- ical 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 consult- ing with the particular payors in question and/or obtaining appropriate legal advice. JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | J u n e 2 0 0 7 33