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DAVID STERN, MD (Practice Velocity)

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 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
  • If the patient simply returned, received the medication from the nurse, and did not see the

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 99211 when coded on the same day of an injection.

Injection Procedures and E/M Codes

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine
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