Fam Pract Manag. 2008 Jul-Aug;15(7):43.
Modifier 25 with E/M and injection codes?
Is it appropriate to attach modifier 25 to the evaluation and management (E/M) code when an injection is also performed? For example, I have been coding 99213-25 with 90772.
Yes. CPT instructs that modifier 25 may be reported when a significant and separately identifiable E/M service is provided with services identified by codes 90760-90779. When reporting injections, be sure to also report the code for each substance injected unless a substance was supplied by another source without cost to you. Note that Medicare and some other payers do not allow separate reporting of code 99211 with most injection services.
How should you report a preoperative physical if the patient has already had an annual physical or does not have preventive care benefits?
Preoperative physicals that are medically necessary to determine whether a patient can safely undergo a procedure or may require special care (e.g., management of comorbid conditions) should be reported with the appropriate office or other outpatient visit or consultation code. Consultation codes are appropriate for these services when you have a documented request for your advice or opinion on the management of the patient from the physician who will perform the procedure. For more information on coding and documenting consultations, including preoperative consultations, see “A Refresher on Coding Consultations,” FPM, March 2007.
E/M services performed solely to comply with the preoperative requirements of a facility may not be medically necessary and often are part of the preservice work that is factored into the payment for the procedure. Such services may not be separately reportable.
If the patient requests the preoperative physical and it is not medically necessary, a preventive medicine service (99381-99397) should be billed directly to the patient.
House calls and private payers
What code should I use for house calls to patients with private insurance? Since some payers do not pay for 99341, can I instead use 99203 with the service location code of 12?
You should report a code from the 99341-99350 series for services provided in a patient's home based on the level of service provided and whether the patient is new or established, as CPT indicates. You should not use 99203, which is designated for reporting E/M services in the physician office, outpatient or other ambulatory facility.
Place-of-service code 12 does identify that services were provided in the patient's home; however, reporting this code with 99203 may result in a claims denial due to an inconsistency in the two codes. Most importantly, this overall approach to coding home visits would be inappropriate from a CPT perspective.
It is a good idea to determine payer guidelines and contractual provisions for home visits, or any other potentially noncovered services, so you can notify patients of noncoverage prior to providing the services. It also helps to ensure that amounts due from the patient are collected at the time of service.
Editor's note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. You should refer to the current CPT and ICD-9 manuals and the Documentation Guidelines for Evaluation and Management Services for the most detailed and up-to-date information.
Copyright © 2008 by the American Academy of Family Physicians.
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